053-4 Wyo. Code R. § 4-2
The report shall be on a form provided by the Division, available from the Division or employer, and shall contain the following information:
(a) The worker's full name, mailing address, telephone number and Social Security Number;
(b) The worker's birth date, sex, marital status and number of dependents;
(c) The employer's full name, address and telephone number;
(d) The worker's date of hire and job title;
(e) A statement of whether the worker is a regular worker, volunteer, inmate, a governmentally subsidized work experience program participant, or has an interest in the business as owner, partner, or corporate officer;
(f) The worker's current monthly earnings;
(g) The date, time and location of the accident or injury;
(h) A statement of how the injury occurred, including what the worker was doing at the time and what objects or substances caused the injury;
(j) A statement identifying the parts of the worker's body affected by the injury;
(k) The name(s) of any witness(es) to the events causing the injury;
(l) The names and addresses of all health care providers who have treated or provided medical services to the worker for the injury being reported;
(m) If the report is prepared by a person other than the worker, the full name, address and telephone number of the person preparing the report, and that person's relationship to the worker;
(n) Such additional information as the Division deems appropriate; and
(o) The report form shall be signed and dated by the worker, or his personal representative if the worker is incapacitated.
053-4 Wyo. Code R. § 4-2