1. AN EFFECTIVE WORK PLACE INJURY INVESTIGATION PROGRAM INVESTIGATIVE SERVICES UNIT MINNESOTA DEPARTMENT OF LABOR AND INDUSTRY TELEPHONE (651) 297-5797 1-888-FRAUD MN (1-888-372-8366) FAX (651) 282-5358

2. First Report  Who is injured?  Time and date injury occurred  Time and date injury reported  Who reported to  Who filled out 1st Report (if different)

3. What is injured?  Where exactly (what body part)  Previous injury to this body part  Treatment when, where, who  Get photographs of the injury

4. How did the injury occur?  Contributing physical conditions  Equipment/mechanical failures  Fell off  Object fell on, etc.  Conditions Day/Night Weather Lighting Surface conditions

5. Pre-injury condition  Normal  Had been drinking  Prescription drugs  Appropriate safety equipment  Disabilities  Illness  Mental condition - personal problems

6. Pre-injury condition  Previous or pending disciplinary action  Impending layoff  Labor relation problems/actions  EE and Supervisor relationship  Co-worker friction  Pre-injury activity  Affirmative action/sexual harassment

7. 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

8. 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

9. Written Statement by EE  Location taken  No rush  EE writes if possible  In ink  ASAP after injury  Pre-injury actions  Actions at time of injury

10. Don’t forget...  Post injury actions  Signed by EE  Copy to EE  EE initials changes  Date and Time  Witness signature  Interviewer observations (body language, eye contact, hostile, etc.)

11. On-site Witnesses Statements  Location at time of injury  Relationship to injured party  Interview individually (no group interviews)  Identified witnesses  Potential witnesses

12. Keep in mind...  Interviewer observations - witness/ER relationship hostile? (body language, eye contact, hostile, etc)  No rush  Unrehearsed  Other possible witnesses (names)

13. Witness Written Statement When taking a witness’ written statement, use the same format as the Written Statement for the Employee.

14. Other Witnesses  HCP - Ambulance, company nurse  Emergency personnel  Police  Uninvolved co-workers  Neighbors

15. 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

16. 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

17.  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.

18. INVESTIGATIVE SERVICES UNIT MINNESOTA DEPARTMENT OF LABOR AND INDUSTRY TELEPHONE (651) 297-5797 1-888-FRAUD MN (1-888-372-8366) FAX (651) 282-5358