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 workers’ compensation specialist in University Benefits at (319) 335-2676.

First Report of Injury Form

To be completed by the employee/supervisor on Employee Self Service under General Systems & Tools 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 the first absence, then weekly thereafter using the Missed Time Weekly Report. The form should be completed on Employee Self Service under General Systems & Tools/Workers' Compensation.

Missed Time Benefit Election Form

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

This report will be sent to the employee when it is reported that the employee will miss (or has missed) three 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. Outlines restricted work assignments due to work-related illness/injury.

No Restricted Work Available Form

To be completed by department to document that accommodations for current restrictions are not available.

Essential and Marginal Functional Job Analysis

As of 2018, Facilities Management, University Housing & Dining, and UI Health Care Department of Nursing use the updated Essential and Marginal Functional Job Analysis form in the case of a new first report of injury submitted through Workers' Compensation.

 

Contact Information

Workers' Compensation

Email
Fax
319-335-2776
Campus Address
120 USB
Mailing Address

120 University Services Building
Iowa City, IA 52242
United States