TEMPLATE

Massachusetts incident report template

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Your Massachusetts incident report has 4 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • Form 101 to the DIA, the employee and the insurer once disability reaches 5 days
  • 5 full or partial days, not necessarily in a row; medical only claims go to the insurer
  • Every OSHA 301 item, completed within 7 calendar days for a recordable case

An incident report template set up for Massachusetts, with fields for the days of full or partial disability so far and form 101 filed with the DIA, the employee and the insurer (date, transmittal number). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Massachusetts Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Days of full or partial disability so far
Form 101 filed with the DIA, the employee and the insurer (date, transmittal number)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Massachusetts rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

  • When an injury incapacitates an employee from earning full wages for five or more calendar days, the employer furnishes notice of the injury on the Division's form to the Department of Industrial Accidents, the employee and the insurer within seven calendar days, not counting Sundays and legal holidays; the notice gives the employer's name and business, the employee's name, age, sex and occupation, and the date, nature, circumstances and cause of the injuryM.G.L. c. 152, s. 6
  • The DIA counts five full or partial calendar days of disability, which need not be consecutive, and expects the Form 101 within seven calendar days (Sundays and legal holidays excepted) after the fifth day; shorter disabilities are medical only claims reported to the insurer, not the DIADIA, When a work-related injury needs to be reported
  • The DIA accepts Form 101 only online, through a DIA account; the filing names the insurer, the injured worker, the date and place of injury, the types of injury and the body parts, and returns a DIA transmittal number to keepDIA, File a Form 101 online
  • Anyone who violates the reporting section three or more times in a year is fined 100 dollars for each violation, and each fine not paid within thirty days of the bill is a separate violationM.G.L. c. 152, s. 6
  • Employers, insurers and medical providers may be required to file additional reports on the injury and the employee's condition, including medical, hospital and rehabilitation records and compensation paymentsM.G.L. c. 152, s. 6
  • A compensation claim cannot proceed unless notice was given to the insurer or employer as soon as practicable after the injury, and the claim is filed within four years of the employee learning the disability is work-relatedM.G.L. c. 152, s. 41

What is in it

  • What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
  • Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
  • Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
  • Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
  • CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
  • Witness statementsName, Role, What they saw or said
  • Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 15, 2026. Read the full Massachusetts incident report requirements.