Employer's First Report of Occupational Injury or Illness Form


TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: October 17, 2000
RE: Employer's First Report of Occupational Injury or Illness Form


I am pleased to make available the Commission’s newly-developed "Employer’s First Report of Occupational Injury or Illness" form. The purpose of this new form is two-fold: (1) to standardize our receipt of the information collected pursuant to C.G.S. § 31-316, and (2) to make available a standard form which can be completed and printed online via our website.

In addition to an original copy enclosed with this mailing, you can print and fill out the Employer’s First Report form online at:


For hard copies of the new form, please contact:

Workers’ Compensation Commission
Education Services
21 Oak Street, 4th Floor
Hartford, CT 06106-8011

Phone: (860) 493-1500
Fax: (860) 247-1361


It is hoped that those of you receiving this memorandum will use the newly-developed form beginning immediately to assist the Commission in providing its services as efficiently and effectively as possible. Thank you for your anticipated cooperation.