Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

First Report of Work-Related Injury or Illness

  1. Town of Frederick
    401 Locust St. Box 435 Frederick, CO 80530
  2. BE SPECIFIC - describe the exact nature of the injury, and which body parts are affected)
  3. Place of Treatment*
  4. If an unauthorized medical provider treats an employee, the employee will be responsible for the payment.
  5. Acknowledgement*
  6. Please type your full name
  7. Important Notes:
    Date of Injury / Illness. Always include the date and time of the injury. In the case of an occupational disease, use the date you were last exposed to the hazard or chemical.

    Injury / Illness Description.
    1. Be more specific than "hurt", "pain" or "sore". Examples: "strained back", "chemical burn, left hand", "sprained right knee." Describe exactly what the injury is, and which part(s) of the body area affected.

    2. Describe the activity, as well as the tools, equipment or material you were using. Be specific. Examples: “climbing a ladder while carrying roofing materials,” “spraying chlorine from hand sprayer,” or “daily computer key-entry.”

    3. Tell us how the injury occurred. Again, be very specific. Examples: “ladder slipped on wet floor, I fell approximately 20 feet and landed on my right knee”; “I was sprayed in the eyes with chlorine when gasket broke during replacement”; “I developed soreness in my left wrist over time due to typing.”

    Return to Work Date
    Employees on worker’s compensation are responsible for keeping their supervisor and HR Department informed of their work status. All disability documentation from the authorized designated treating physician, noting the employee’s dates of absence from work and the diagnosis of the injury or illness, must be provided to the HR Department immediately. If this documentation is not provided to the HR Department, the employee’s continued absence from work will be considered unauthorized and workers compensation benefits may be suspended.

    When an employee is able to fully return to work, written clearance from the treating physician documenting that the employee is fully capable of performing regular job duties MUST be provided to the HR Department.
  8. Leave This Blank:

  9. This field is not part of the form submission.