AN EFFECTIVE WORK PLACE INJURY INVESTIGATION PROGRAM

INVESTIGATIVE SERVICES UNITMINNESOTA DEPARTMENT OF LABOR AND INDUSTRY

TELEPHONE (651) 297-5797

1-888-FRAUD MN

(1-888-372-8366)

FAX (651) 282-5358

First Report

Who is injured?Time and date injury occurred

Time and date injury reported

Who reported toWho filled out 1st Report (if different)

What is injured?

Where exactly (what body part)

Previous injury to this body

part

Treatment when, where, who

Get photographs of the injury

How did the injury occur?Contributing physical conditions Equipment/mechanical failures Fell off Object fell on, etc. Conditions

•Day/Night•Weather•Lighting•Surface conditions

Pre-injury condition

NormalHad been drinkingPrescription drugsAppropriate safety equipmentDisabilitiesIllnessMental condition - personal problems

Pre-injury condition

Previous or pending disciplinary action

Impending layoffLabor relation problems/actionsEE and Supervisor relationshipCo-worker frictionPre-injury activityAffirmative action/sexual harassment

Statements Obtained

Statement From EE Taken by "respected" upper level manager

Non-adversarial setting Demonstrate concern and empathy Immediate and ongoing positive personal contact

First unrehearsed statement

Remember...

Let them talk Names of Witnesses No rush Geographical location of injury

•Return to accident site (if possible)

•Re-enactment of injury•Photos and or video

Written Statement by EE Location takenNo rushEE writes if possibleIn inkASAP after injuryPre-injury actionsActions at time of injury

Don’t forget...

Post injury actionsSigned by EECopy to EEEE initials changesDate and TimeWitness signatureInterviewer observations (body language, eye contact, hostile, etc.)

On-site Witnesses StatementsLocation at time of injury

Relationship to injured party

Interview individually (no

group interviews)

Identified witnesses

Potential witnesses

Keep in mind...

Interviewer observations - witness/ER relationship hostile? (body language, eye contact, hostile, etc)

No rush

Unrehearsed

Other possible witnesses (names)

Witness Written Statement

When taking a witness’

written statement, use the

same format as the Written

Statement for the Employee.

Other Witnesses

HCP - Ambulance, company

nurse

Emergency personnel

Police

Uninvolved co-workers

Neighbors

Additional EE Information. This information should be obtained at time of employment and up-dated annually.

Name (first, middle, last - no

initials)

Nicknames, maiden name, previous name

Date of Birth

SSN

Driver's License number

Current address

Previous address, when

Are you moving? when and where

More important information... Phone # current

Pager #

Cell Phone #

Part-time employer name, address, phone

Immediate family contact address, phone

Non-relative contact address, phone

Vehicle type, year, license #

Interests, hobbies

The foregoing information is only intended to be used as a guide in the investigation of workers' compensation claims. It is the responsibility of the claims representative to fully investigate claims using procedures and guidelines established by their employer.

INVESTIGATIVE SERVICES UNIT

MINNESOTA DEPARTMENT OF LABOR AND INDUSTRYTELEPHONE (651) 297-5797

1-888-FRAUD MN(1-888-372-8366)

FAX (651) 282-5358