NORTH DAKOTA DEPARTMENT OF AGRICULTURE
WORKERS COMPENSATION EMPLOYEE CHECK LIST AND INFORMATION
(2-08)

__1.  If an individual is injured while conducting business on behalf of the State of North Dakota, Department of Agriculture:

a. In an emergency, seek immediate medical care at the nearest emergency room. Notify the health care provider that your injury is a workers' compensation injury and also notify your supervisor or employer as soon as possible that an injury occurred.

b. In all other instances, notify your employer that you have been injured before seeking any medical care.  The department participates in the Risk Management Program and has a designated medical provider (DMP).  You are required to see that provider for medical care, unless you had previously informed the department, in writing, of a different medical provider selection before any injury occurred.  Failure to go to the DMP for an injury may result in nonpayment of medical benefits and/or claim denial.

c. If no medical treatment is required, complete the medical treatment waiver form.

__2.  Complete a WSI “First Report of Injury” (FROI).  The risk management coordinator will assist the injured individual with completing the FROI,  which can be submitted online at:  http://www.workforcesafety.com/workers/onlineservices.asp ; or by telephone: 1-800-777-5033 24 hours a day, 7 days a week. The FROI form used to telephonically record the claim will be sent to the worker for signature. They must return the form to WSI as soon as possible.

__3. The risk management coordinator will also assist with completion of the Risk Management Incident Report, which should be submitted online at: http://www.nd.gov/risk/riskvision/application/sond/rmis/Incidents/default.asp?guest=true

__4. The program manager will conduct an investigation and complete the Initial Accident Investigation/Near Miss Report NDDA SFN: 602 RMP 001 and give it to the risk management coordinator.

The written accident investigation report may include the following elements:

• Inspection of the accident site.
• A determination of the reasons why the incident happened.
• The circumstances surrounding the incident.
• Securing evidence and taking photographs.
• Interviewing all witnesses and others in the accident area and writing down their statements. Interviews should be conducted in a sensitive manner at a comfortable location.
• An outline of the necessary corrective action that will be taken to prevent the injury from happening again.

Timeframes for Reporting an Injury:

-Employees are encouraged to immediately (within 24 hours of occurrence and after medical treatment is received) file a claim with WSI after a work-related injury occurs.

- State law requires that employees notify employers within 7 days after an accident or when the general nature of the injury becomes apparent. Within 7 days of receiving notice of an injury from the employee, the employer is required to file a claim with WSI.