Instructions for Completing a FROI

The FROI-1 is a BWC form used as a means of reporting a work-related injury. The form contains 4 sections:

1. Injured Worker
2. Injury/Diseases/Death
3. Treatment
4. Employment

The FROI-1 should be filled out as completely as possible and faxed to CompManagement Health Systems within 24 hours of the first date of service.

SECTION 1: INJURED WORKER - This section should be completed by the injured worker.

1. ** LAST NAME, FIRST NAME, MIDDLE INITIAL: Enter injured worker´s last name, first name, and middle initial.
2. ** SOCIAL SECURITY NUMBER: Enter injured worker´s 9 digit Social Security Number.
3. ** MARITAL STATUS: Enter injured worker´s marital status.
4. ** DATE OF BIRTH: Enter injured worker´s date of birth.
5. ** HOME ADDRESS: Enter injured worker´s home address.
6. ** SEX: Enter male or female.
7. NUMBER OF DEPENDENTS: Enter number of Injured worker´s dependents.
8. CITY, STATE, 9-DIGIT ZIP CODE: Enter the injured worker´s city, state,zip code.
9. COUNTRY IF DIFFERENT THAN U.S.A. : Enter the appropriate country if it is not U.S.A.
10. DEPARTMENT NAME: Enter injured worker´s department name in which he/she works.
11. WAGE RATE: Enter injured worker´s wage rate and frequency.
12. WHAT DAYS OF THE WEEK DO YOU USUALLY WORK: Check the appropriate box(es).
13. REGULAR WORK HOURS: Enter injured worker´s regular work hours.
14. HAVE YOU BEEN OFFERED OR DO YOU EXPECT TO RECEIVE PAYMENT FOR THIS CLAIM FROM ANYONE OTHER THEN THE OHIO BUREAU OF WORKERS COMPENSATION: Check the appropriate box.
15. OCCUPATION OR JOB TITLE: Enter injured worker´s occupation or job title.
16. BENEFIT APPLICATION/MEDICAL RELEASE: Sign the medical release, including job title and date signed.
    

SECTION 2: INJURY/DISEASE/DEATH - This section should be completed by the injured worker.

1. ** DATE OF INJURY/DISEASE: Enter date of injury or disease.
2. TIME OF INJURY: Enter time of injury and indicate either AM or PM.
3. IF FATAL, GIVE DATE OF DEATH: Enter date of death, if applicable.
4. DATE LAST WORKED: Enter date last worked.
5. DATE RETURNED TO WORK: Enter return to work date, if applicable.
6. ACCIDENT LOCATION: Enter street address of accident location.
7. DATE HIRED: Enter date hired.
8. STATE WHERE HIRED: Enter state hired.
9. DATE EMPLOYER NOTIFIED: Enter date employer notified.
10. CITY: Enter accident city.
11. STATE: Enter accident state.
12. WAS PLACE OF ACCIDENT OR EXPOSURE ON EMPLOYER´S PREMISES? Check appropriate box.
13. DESCRIPTION OF ACCIDENT: Enter the accident description. The description should be as detailed as possible, including a description of the mechanism of injury (i.e. I slipped on the wet floor while mopping and fell on my left knee.)
14. TYPE OF INJURY: Enter type of injury and part(s) of body affected. (i.e. sprain of left shoulder, etc.)
    

SECTION 3: TREATMENT - This section should be filled out by the provider.

1. ** PHYSICIAN/HEALTH CARE PROVIDER NAME: Enter name of provider.
2. TELEPHONE NUMBER: Enter provider telephone number.
3. FAX NUMBER: Enter provider fax number.
4. INITIAL TREATMENT DATE: Enter first date of service.
5. STREET ADDRESS: Enter provider´s physical address.
6. CITY: Enter provider city.
7. STATE: Enter provider state.
8. 9 DIGIT ZIP CODE: Enter zip code(ZIP+4, if possible)
9. ** DIAGNOSIS(ES): Enter ICD-9 code(s)
10. ** WILL THIS INCIDENT CAUSE THE INJURED WORKER TO MISS 8 OR MORE DAYS OF WORK? Check the appropriate box. (This is the providers opinion.)
11. ** IS THIS INJURY CAUSALLY RELATED TO THIS INDUSTRIAL INCIDENT? Check the appropriate box. (This is the provider´s opinion as to whether the injury treated relates to the description of the accident. It is not a legal opinion.)
12. ** PROVIDER SIGNATURE/DATE: Sign provider name.
13. ** BWC PROVIDER NUMBER: Enter provider´s 11-digit BWC Provider Number.
14. ** DATE
    

SECTION 4: EMPLOYMENT - This section should be completed by the employer.

1. ** EMPLOYER NAME: Enter injured worker employer name.
2. POLICY NUMBER: Enter employer policy (risk) number.
3. CHECK IF: Mark appropriate box if either apply.
4. ** MAILING ADDRESS: Enter employer mailing address.
5. COUNTY: Enter employer county
6. LOCATION, IF DIFFERENT FROM MAILING ADDRESS: As stated
7. MANUAL NUMBER: Enter employer manual number.
8. ** TELEPHONE NUMBER: Enter employer telephone number.
9. FAX NUMBER: Enter employer fax number.
10. FEDERAL ID NUMBER: Enter employer federal ID number.
11. CERTIFICATION/REJECTION INFORMATION: Check the appropriate box. If the certification is rejected, document a reason on the following lines.
12. EMPLOYER SIGNATURE/TITLE, DATE, and TELEPHONE NUMBER: Employer representative signature, Name, Title, and date application.
13. OSHA CASE NUMBER: If available.

Click here to download the FROI form