Workers' Compensation Forms
Several Workers’ Compensation (WCI) forms may need to be completed during the duration of a WCI claim. Timely submission of these forms is required by law; completed documents must be submitted to Human Resources as soon as possible at the contact information below.
- First Report of Injury or Illness
First Report Instructions
This form must be completed once that we, as an employer, become aware of any workplace injury. This must be done, regardless of whether or not the injury is considered serious or if the accident occurred within the course and scope of duties. Please note the following additional items regarding this form:
- The first report must be completed by the supervisor or WCI designee; the form may not be completed by the employee.
- All information must be completed on the form; please use the instructions above to ensure the information is complete and accurate. Incomplete forms will delay the processing of a WCI claim, which in turn may become a violation of state law.
- A separate handout, entitled “Notice of Injured Employee Rights and Responsibilities”, must be provided to each employee who suffers a workplace injury.
- Witness Statement
This form should be filled out by a willing witness who personally witnessed a work-related injury. It may be submitted with the first report, if possible, or in a timely manner after the first report has been submitted.
- Request for Paid Leave
Request for Paid Leave Instructions
This form should be completed by the WCI liaison as soon as the department becomes aware that the employee is losing time due to a work-related injury. Lost time is defined as missing more than one shift of work. The form may be completed by the WCI liaison or designee if the employee is unavailable for a signature, provided the employee is consulted first regarding the choice of leave to use.
- Supplemental Form of Injury or Illness
Supplemental Form of Injury or Illness Instructions
This form accounts for any period of time lost from work for which the injured worker might be entitled to Workers’ Compensation benefits. It also serves as written notice of an employee's time lost from work and return to work after a period of temporary disability or of any change in pay status.
- Wage Statement
Wage Statement Instructions
This form is required whenever the employing department knows (or should have known) an employee will miss more than seven (7) cumulative days for a work-related injury.
Early Return to Work Program
Please note that departments are obligated to attempt, in good faith, to provide meaningful temporary work to those employees who are required to work under a physician’s restrictions or limitations. Please review additional information regarding the
University’s Early Return to Work Program if your employee has restrictions regarding his or her return-to-work status.
Additional Information:
