First Report of Injury or Illness

Labor Commission Form 122

Worker's Compensation Employer's First Report of Injury or Illness
State of Utah - The Labor Commission - Division of Industrial Accidents

Required fields for claim processing have been highlighted in yellow. The form will submit if these fields are not filled in, but the claim processing may be delayed while the missing information is collected.

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Employer Name
Employer Address
City
State	Zip Code

Industry Code

Employer FEIN

OSHA Log Number

Insured Report Number

Employer's Location Address (if different)
City
State	Zip Code

Location #

Phone #

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Last Name	First Name
Middle Name
Address (If unknown, type unknown)
City
State	Zip Code
Home Phone (999-999-9999)	Work Phone Ext.

Date of Birth

(MM/DD/YYYY)

Gender

# of Dependents

Social Security Number
- -

Date Hired

(MM/DD/YYYY)

Hire State

Marital Status

Occupation/Job Title

Employment Status

NCCI Class Code

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Rate $	per
If other:

# of Days Worked / Week

Full Pay for Day of Injury?	Yes No
Did Salary Continue?	Yes No

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Time Employee Began Work
HH:MM

Date of Injury/Illness

(MM/DD/YYYY)

Time of Occurrence
HH:MM

Last Work Date

Date Employer Notified

(MM/DD/YYYY)

Date Disability Began

(MM/DD/YYYY)

Contact Name

Contact Phone #
Ext. (999-999-9999)

Type of Injury/Illness

Part of Body Affected

Did injury/illness exposure occur on employer's premises?
Yes No

Department or location where accident or illness exposure occurred
Address

City
State	Zip Code

All equipment, materials, or chemicals employee was using when accident or illness exposure occurred:

Specific activity the employee was engaged in when the accident or illness exposure occurred. (Use multiple lines if needed.)

Work process the employee was engaged in when accident or illness exposure occurred

How injury or illness/abnormal health condition occurred, describe the sequence of events and include objects or substances that directly injured the employee or made the employee ill

Date return(ed) to work

(MM/DD/YYYY)

If fatal, give date of death

(MM/DD/YYYY)

Were safeguards or safety equipment provided?	Yes No
Were they used?	Yes No

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Physician/Health Care Provider Name
Address

City
State	Zip Code

Hospital Name
Address

City
State	Zip Code

Initial Treatment:
No Medical Treatment
Minor: by Employer
Minor by Clinic/Hospital
Emergency Care
Hospitalized > 24 hours
Future Major Medical/Lost Time Anticipated

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Witness Name

Phone #
Ext. (999-999-9999)

Preparer's Name

Preparer's Title

Phone Number
Ext. (999-999-9999)

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