Workers' Compensation

Campus Address
120 USB
Mailing Address

120 University Services Building
Iowa City, IA 52242
United States

Below are examples of various forms that you might need to fill out in case of a work-related injury. If you have any questions about completing these forms, please reach out to the Workers' Compensation team in University Benefits by calling (319) 335-2676, or emailing 

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 form will be sent to the employee when it is reported that the employee will miss (or has missed) more than 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.

Temporary Restricted-Duty Letter 

To be completed by designated departmental staff and employee. Outlines temporary restricted work assignments due to work-related illness/injury.

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 Job Function Analysis form in the case of a new first report of injury submitted through Workers' Compensation.