First Report of Workplace Injury (FROI)

Employees should report work-related injuries to their supervisor or other person designated by your department as soon as possible but no later than one business day after an injury. (Injured employees should not complete this form.)


Supervisors or designated staff must report all work-related injuries to the Office of Compliance and Risk Management (OCRM) using the online reporting form at the link below on the same business day notification of an injury is received. Reporting a work-related injury also starts the Worker's Compensation claims process with Human Resource Management (HRM).


If there is an accident, illness, or injury that results in or may result in death, serious injury, or injury that requires hospitalization, the incident must be reported by telephone immediately to OCRM at 662-325-6280.



DO NOT DELAY REPORTING - If any information requested on this form is unknown at the time of reporting, it can be provided at a later date. Only the items marked with an (*) are required for initial reports.

Incident Details

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Did the injury/illness exposure occur on campus or on an MSU location?*
Oktibbeha
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Explain the nature of the injury/illness experienced.

Select the option that best defines the cause of the injury/illness obtained.

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Choose one that's the most appropriate.

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Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker's right wrist was broken in the fall.

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander, paintbrush, and paint. Enter "NA" for not applicable if no equipment, materials, or chemicals were being used.

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.

Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter "NA" for not applicable if employee was not engaged in a work process (e.g., walking along a hallway).

Were safeguards or safety equipment provided?*
Were safeguards or safety equipment used?*
Was the injury witnessed?*
Phone
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Were cameras present in the area?

(i.e. Department Incident Reports, Photos of Injury Location)

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Treatment

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Employee Information

Enter in order from first name to last.

Enter either the employee's net ID or MSU 9-digit ID number.

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Phone
Mississippi
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Sex*
Marital Status
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Employment Status*
Is the employee's pay rate yearly or hourly?
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Department Contact Information

Phone

Did someone other than a supervisor complete this form?*
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