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Workers and Physicians Report of Injury Form

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Employer's Report of Industrial Injury

Industrial Commission of Arizona
P.O. Box 19070
Phoenix, Arizona 85005-9070

Complete and mail this report within 10 days from notice of accident. Fatalities must be reported within 24 hours.

Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise out of or in the course of employment. Arizona Revised Statutes 23-908 & 23-1061.

Mail to:

For Carrier Use Only

OSHA Case #:

Recordable Injury Non-Recordable Injury

Employee

1. Last Name: First: M.I.:

2. Social Security Number:

3. Birth Date:

4. Home Address: City: State: Zip Code:

5. Telephone:

7. Marital Status:

Sex:

Employer

8. Employer's Name:

9. Policy Number:

10. Nature of Business:

11. Office Address: City: State: Zip Code:

12. Telephone:

Accident

13. Date of Injury or Illness:

14. Time of Event: A.M. P.M.

15. Time Employee Began Work: A.M. P.M.

16. Date Employer Notified of Injury:

17. Last Day of Work After Injury:

18. Date of Return to Work:

19. Employee's Occupation (Job Title) When Injured:

20. Class Code on Payroll Report:

21. Employee's Assigned Department:

22. Department Number:

23. Did Injury Occur on Employer Premises? Yes No

24. Address or Location of Accident: City: County: State: Zip Code:

25. What Was the Injury or Illness?

26. Part of Body Injured:

27. Fatal: Yes No

28. If the Employee Died, When Did the Death Occur? Date of Death:

29. Was Employee Treated in an Emergency Room? Yes No

Name of Physician or Other Health Care Professional:

Address:

30. Was Employee Hospitalized Overnight as an In-Patient? Yes No

If Hospitalized, Hospital Name:

Address:

31. If Validity of Claim Is Doubted, State Reason:

Cause of Accident

32. What Happened?

33. What Object or Substance Directly Harmed the Employee?

34. What Was Employee Doing Just Before the Incident Occurred?

35. If Another Person Not in Company Employ Caused Accident, Give Name and Address:

Employee's Wage Data

36. Was Worker in Your Employ When Injured? Yes No

37. Hours Per Day Employee Worked: From Thru

38. Was Employee on Overtime When Injured? Yes No

39. Number of Days Per Week Usually Worked:

40. Date of Last Hire:

41. Was Worker Paid for Day of Injury? Yes No

42. Was Employee Hired for Permanent Employment? Yes No

43. Number of Months Employment Available During the Year:

44. Give Employee's Wage Status as Applicable:

45. Is Employee Furnished Value? $ Per Board $

46. Actual Gross Earnings of Employee for the 30 Calendar Days Preceding Injury:

47. Does Employee Claim Dependents? Yes No

48. If Employee Earns Extra Pay for Overtime, What Is Basis of Payment?

49. Number of Hours Overtime Considered Normal Per Week:

50. Gross Wages of Employee During 12 Months Preceding Injury: From Thru

51. If Employee Worked Less Than 12 Months, Show Gross Wages From Date of Hire Through Day Prior to Injury:

52. Date of Last Wage Increase if Within 12 Months Prior to Injury:

53. Wage Before Increase: $

54. Wage After Increase: $

55. Gross Earnings From Date of Increase Thru Day Prior to Injury: $

Authorized Signature:

Date:

Title:

Note to Employer

1. Mail one copy to the Industrial Commission within 10 days.

2. Mail one copy to your insurance carrier within 10 days.

3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970.

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What the Workers and Physicians Report of Injury Form Is

The Workers and Physicians Report of Injury Form documents a workplace injury and the treating clinician's findings to support workers' compensation claims, employer incident investigations, and regulatory reporting. Employers or safety teams record incident facts, while treating physicians complete medical sections describing diagnosis, treatment, and work restrictions. The completed form creates a contemporaneous record for insurers, state agencies, and legal review, and it supports return-to-work planning. When medical information is included, protect patient privacy in accordance with HIPAA and applicable state law.

Why consistent, accurate reporting matters

Standardized injury reports speed claims handling, reduce administrative disputes, and preserve medical and investigatory evidence. Complete forms make it easier to coordinate care, document work restrictions, and meet insurer or state reporting requirements while limiting downstream legal and operational friction.

Why consistent, accurate reporting matters

Who completes and relies on this form

Employers, HR or safety teams, treating clinicians, and insurers jointly use the form to capture incident facts, medical findings, and administrative details needed for claims and workplace safety.

  • Employers — HR or safety teams responsible for initial incident reporting and insurer notification.
  • Treating physicians — complete medical sections, document diagnosis, and recommend work restrictions.
  • Insurers and adjusters — evaluate compensability, estimate benefits, and coordinate claim investigations.

Core sections included in a professional report

A complete form groups incident facts, injured worker identity, clinical findings, work-status instructions, billing details, and routing metadata so each reader can locate the data needed for claims, care, or compliance.

Incident Details

Record date, time, location, activities, and immediate cause. Include witness names and contact information to support investigation and insurer inquiries. Note environmental factors and equipment involved.

Injured Worker

Provide full legal name, job title, employer, address, date of birth, and contact details. Accurate matching to payroll records prevents delays in benefits and TIN validation.

Medical Findings

Treating physician documents diagnosis, examination findings, required treatment, medications, and work restrictions. Include objective test results and recommended follow-up visits or referrals.

Work Status

Record restrictions, modified duty, full or partial return dates, and anticipated duration. Clear work-status entries guide accommodation, disability pay, and payroll adjustments; document temporary limitations.

Billing Codes

Include procedure and diagnosis codes (CPT, ICD-10) when applicable and attach relevant test reports. Accurate coding supports insurer processing and reduces denial risk.

Reporting & Routing

List insurer name, policy and claim numbers if available, and state agency contacts. Note dates filed and submission method to create an auditable trail.

Required fields at a glance

Full Name: Enter legal name as on ID
Date of Injury: Use MM/DD/YYYY format; include time
Injury Description: Be specific about body part
Physician Name: Include license number and contact
Employer Info: Provide legal entity and address
Claim Number: Enter insurer claim number if assigned

Step-by-step: complete and submit the form

Complete the form promptly after initial evaluation; follow the steps below to gather data, document clinical findings, and file with the insurer and any required state agency.

  • 01
    Step 1: Gather worker and incident details
  • 02
    Step 2: Have physician complete medical sections
  • 03
    Step 3: Verify employer and insurer details
  • 04
    Step 4: Submit to insurer and retain copy

Configuring an online workflow for this form

Typical online configuration options let you enforce fields, set signer order, and route completed PDFs to insurers, HR, and safety teams automatically.

Form Field and Workflow Configuration Field Name | Setting
Signature Field Signature | Required for physician and employer
Authentication Authentication | Email link or SMS code
Routing Routing | Send to insurer then HR
Retention Retention | Save PDF and audit trail

Typical submission flow from completion to filing

A clear transmission path ensures the form reaches the insurer, HR, and state agency as required and that the signed record is retained for audit and care coordination.

  • Prepare: Gather details and open the form online
  • Complete: Fill worker and clinical sections accurately
  • Authenticate: Confirm signer identity via email or SMS
  • Transmit: Send to insurer, HR, and retain copy

Digital platform requirements and file formats

Use an e-signature platform that provides an audit trail, secure storage, and a HIPAA-compliant deployment option when handling protected health information.

  • Authentication: Email, SMS, or stronger options
  • Formats: PDF and Word DOCX supported
  • Integrations: Connect to HR and claims systems

Key timelines and filing expectations

Timely filing and documentation preserve claim rights and satisfy insurer and regulatory reporting rules; exact deadlines vary by insurer and state.

Immediate Medical Care:

Provide treatment and document in form same day

OSHA Serious Injury Reporting:

Report fatalities within 8 hours, hospitalizations within 24 hours

Employer to Insurer:

Notify insurer per policy within 24–72 hours

State Agency Filing:

Some states require written reports within 3–10 days

Record Retention Start:

Retention period begins on the incident date

Common mistakes to avoid when preparing the form

  • Leaving key fields blank (date, time, body part) creates follow-up delays and can delay benefits while investigations proceed.
  • Using inconsistent names or formats between payroll, medical records, and the form causes identity verification and TIN-matching failures.
  • Omitting physician signature, license number, or exact work restrictions can lead to claim denials or unpaid accommodation requests.
  • Failing to retain a signed copy and audit trail prevents proof of timely submission during disputes or regulatory audits.

Potential penalties and operational risks

Claim Delay: Benefits may be delayed
Denial Risk: Incomplete forms increase denial chances
Regulatory Fines: State penalties possible for late reporting
HIPAA Breach: Improper PHI handling raises breach liability
Increased Litigation: Poor records increase dispute likelihood
Payroll Errors: Misstated work status affects pay

Practical examples showing common usage

Two real-world examples demonstrate how organizations use the form to capture medical details, route claims, and keep auditable records.

Optica Ventures — COO

Optica implemented online injury reporting to reduce paper handling and ensure consistent capture of incident and medical data across mobile teams.

  • Mobile access simplified collection and signoff across locations.
  • Brian Fitzgibbons noted the interface is simple and easy-to-use for the team and for customers, helping the company close reports faster while maintaining documentation.

Fertility Centers — Founder

A clinical practice converted physician-completed reports to an electronic workflow to centralize records and preserve HIPAA protections.

  • Electronic routing improved tracking and reduced lost forms.
  • John Butler reported the API and responsiveness allowed the practice to meet compliance and operational needs while retaining secure audit trails.

Typical signatories and authorized approvers

Employer HR Manager

Human resources or risk managers typically approve the administrative sections, confirm employer details, and authorize routing to insurers and safety teams for follow-up and corrective action.

Treating Physician

The clinician provides diagnosis, work status, and recommended restrictions; their signature and license number authenticate the medical findings for benefits adjudication.

eSignature vendor comparison for completing and routing the form

Neutral comparison of common vendor attributes relevant to secure signing, bulk routing, and HIPAA-capable deployments; signNow is listed first for parity in the table below.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes Varies
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Varies Varies Varies Varies
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions and troubleshooting

Answers to common questions about form validity, signatures, privacy, and how to correct or update a submitted report.


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