Workers' Compensation Forms

Several Workers' Compensation Insurance (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

• Must be submitted online through the Origami Portal (link above)
  • No login required
  • For details, review the Incident Entry Quick Reference.
• Use of the Lookup function when completing the incident is critical to ensure data is populated correctly from Workday (identified by "Lookup" or the search magnifying glass).
  • Please be aware that the Workers' Compensation (WC) liaison is an employee on the HR staff, not at the departmental level. For Texas A&M Health Science Center, the WC liaison is Kathy Miller.
• Fill in all information and select Complete Incident. Immediately send an email to Employee-Relations@tamu.edu (TAMU) or kathy.miller@tamhsc.edu (HSC) for proper processing.
• The employee, employee's supervisor and Workers' Compensation liaison receive an email regarding the incident.
• Submit your first report within 24 hours to ensure compliance for timely submission.

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

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. Instructions for completing the form are available.

Supplemental Form of Injury or Illness

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. Instructions for completing the form are available.

Wage Statement

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. Instructions for completing the form are available.

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.