Workers' Compensation Forms

Following are examples of several forms (and directions when applicable) that you may need to complete when an injury occurs. If you have questions regarding the completion of any of these forms, contact your supervisor, your claims representative, or the University Workers’ Compensation Specialist in the Benefits Office at (319) 335-2676.

First Report of Injury Form

To be completed by the employee/supervisor on Employee Self Service site under HR Applications within 24 hours of report of injury. Submitted by the University to appropriate parties documenting the work injury.

Missed Time Weekly Report

To be completed by designated departmental staff to report employee hours of work, and restricted work assignments/hours etc. If the employee will be missing at least a full day of work, the supervisor must notify Benefits within 24 hours of first absence, then weekly thereafter using the Missed Time Weekly Report.  Form should be completed on Employee Self Service site under HR Applications/Systems/Workers' Compensation.

Missed Time Benefit Election Form

To be completed by employee permitting/directing UI Benefits to supplement workers’ compensation benefits with accrued leave.

This report will be sent to the employee when it is reported to Workers' Compensation that the employee will (or has) missed 3 days of work.

Mileage Reimbursement Form

To be completed by the employee and submitted on a monthly basis to Sedgwick CMS for reimbursement of necessary travel expenses (e.g., mileage, parking, etc.) related to a covered workers’ compensation claim. The employee is encouraged to keep a copy of this document for their records.

Restricted Work Assignment Form

To be completed by designated departmental staff and employee. Information outlines the restricted work assignment due to work-related illness/injury.

No Restricted Work Available Form

To be completed by department outlining that accommodations for current restrictions not available.