North Dakota Employee Written Work Injury Notice
NORTH DAKOTA EMPLOYEE WRITTEN WORK INJURY NOTICE
Before you send this: Give notice immediately after an accident at work. Under N.D. Cent. Code § 65-05-01.2, oral or written notice goes to the immediate supervisor or another supervisor authorized to receive it; absent good cause, the outside period is seven days after the accident or after the general nature of the injury becomes apparent. This written copy records the notice. The employer's First Report to WSI and the worker's benefits claim are separate steps.
Notice date: [__/__/____]
To immediate or authorized supervisor: [NAME / TITLE]
Employer and worksite: [EMPLOYER NAME / WORKSITE]
From employee: [FULL NAME]
Employee contact information: [MAILING ADDRESS / PHONE / EMAIL]
Accident and apparent injury
I notify you that an accident occurred while I was on the job.
Accident date and time: [DATE] at [TIME]
Place of accident: [WORKSITE AND SPECIFIC LOCATION]
What happened: [BRIEF FACTUAL DESCRIPTION]
General nature of injury, if apparent: [BODY PART AND DESCRIPTION, OR "NOT YET APPARENT"]
When the general nature of the injury first became apparent: [DATE / TIME, OR "NOT YET APPARENT"]
Earlier oral notice, if any: [SUPERVISOR / DATE / TIME / METHOD, OR "NONE"]
Please confirm receipt and arrange the employer's First Report of Injury to WSI. I understand that this supervisor notice does not itself complete a claim for benefits on WSI's form.
Employee signature: ______________________________ Date: [__/__/____]
Delivery record — retain with a copy
Supervisor who received this notice: [NAME / TITLE]
Delivery method and destination: [HAND DELIVERY / MAIL / ELECTRONIC METHOD AND ADDRESS]
Delivery or confirmed receipt date and time: [DATE / TIME]
Proof retained: [ACKNOWLEDGMENT / RECEIPT / EMAIL RECORD / OTHER]
Official sources
About this template
- Last updated
- November 4, 2026
- Citations checked
- November 4, 2026
- Jurisdiction
- North Dakota
- Category
- Employment & HR
Legal authority
- N.D. Cent. Code § 65-05-01.2
- N.D. Cent. Code § 65-05-01.4
- N.D. Cent. Code § 65-05-02
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on November 4, 2026.
N.D. Cent. Code § 65-05-01.2 (content and method) (checked November 4, 2026): "the employee shall take steps immediately to notify the employer that the accident occurred and what is the general nature of the injury to the employee, if apparent. Notice may be either oral or written."
N.D. Cent. Code § 65-05-01.2 (recipient and timing) (checked November 4, 2026): "The notice must be given to the employee's immediate supervisor or another supervisor authorized to receive notice. Absent good cause, notice may not be given later than seven days after the accident occurred or the general nature of the employee's injury became apparent."
N.D. Cent. Code § 65-05-01.4 (employer report) (checked November 4, 2026): "The employer shall file a first report of notice of injury with the organization within seven days from the date the employer receives the notice of injury from the employee."
N.D. Cent. Code § 65-05-02 (claim form) (checked November 4, 2026): "Every claim must be made on forms to be furnished by the organization and must contain all the information required by it."
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