Workers' Compensation Forms

• First Report of Injury or Illness:  Initial form to report an injury or illness.
• Witness Statement:  Form for witnesses to provide their account of the incident.
• Request for Paid Leave:  Form to request paid leave during recovery.
• Supplemental Form of Injury or Illness:  Additional information form for ongoing claims.
• Wage Statement:  Documentation of wages for compensation purposes.
• Contaminated Sharps Injury Reporting Form:  This form must be completed by all faculty, staff, and students who experience a contaminated sharps injury.

Early Return to Work Process and Forms

• Early Return to Work Process:  Guidelines for returning to work after an injury.
• Early Return to Work Forms:  Required forms for the early return to work process.
• Related Information and Links:  Additional resources and links related to workers’ compensation.

• Early Return to Work Program:  Information on the procedures and benefits of returning to work after a work-related injury, including modified duties and the importance of early return for recovery and productivity.
• FMLA Leave:  Information on employee eligibility, rights, and responsibilities under FMLA, including how to apply for leave, required documentation, and the process for managing FMLA leave.
• HR Incident Guide:  Guide for Employee Relations to verify and submit incidents to WCI for claims processing.
• TDI Workers' Compensation Forms: This page provides a numeric listing of workers' compensation forms, including the Employer’s First Report of Injury or Illness, Employer’s Wage Statement, and Request for a Required Medical Examination.
• Workers' Compensation Insurance Program:  Outlines the WCI program, detailing medical coverage, disability payments, and the process for reporting work-related injuries.
• Workers' Compensation Insurance Guide:  Provides comprehensive information on the WCI program, including coverage details, reporting procedures, and guidelines for managing work-related injuries and illnesses.

Click the "Ask a Workers' Compensation Question" button on the top right of this page.  Complete the required fields and submit the request. You will receive an open ticket notification.  If additional information is needed, you will be contacted by the respective support team.  Ticket status can be tracked in the portal under the View Tickets tab.

NOTICE:  Protecting Your Privacy and Ensuring HIPAA Compliance
At HROE, we are dedicated to safeguarding your privacy and ensuring full compliance with the Health Insurance Portability and Accountability Act (HIPAA). Please note that TeamDynamix is not designed to store or manage any personal identifiable information (PII) or protected health information (PHI).
 
To uphold the highest standards of data protection, we kindly ask that you refrain from sharing any PII or PHI in this electronic form.