Injury/ Illness Forms
If you sustain a work-related injury or illness, the worker’s compensation program is in place to provide financial coverage for treatment and time lost from employment [footnote (i)].
In the event of a work-related injury or illness, you are responsible for the following:
First things first
- Seek first aid and/or medical treatment immediately if needed [footnote (ii)].
- Within 24 hours of the time of the accident or injury:
- Report the accident or injury to your supervisor.
- Complete and submit Employee’s Work Injury and Illness Report to your supervisor. Forms available in sidebar at left.
- Notify your supervisor of any unsafe work conditions.
Be sure to…
- Tell your medical care provider your injury is work-related.
- Comply with medical directions and actively participate in your recovery process.
- Give certain paperwork that you may receive from medical professionals to your supervisor. This will include:
- medical releases,
- medical proof that injury or illness is work related, and
- restrictions certificate of work restrictions.
- Maintain contact with your supervisor and worker’s compensation coordinator through the course of this claim. Notify your supervisor of any changes such as scheduled surgery, return to work, etc.
- Respond to Worker’s Compensation Claims Examiner’s information request to expedite claim.
- Participate in the return to work process Early Return To Work Program and/or alternate duty assignment as directed by your supervisor.
- If medical treatment is required:
- Complete an authorization form:
- If any of the following types of treatment are recommended by your health care provider, promptly notify your worker’s compensation coordinator prior to having the treatment:
- inpatient hospitalizations
- surgical procedures
- MRI and CT scans
- physical therapy
- chiropractic treatment
- You must send the original of all medical bills from your injury/ illness to your campus Worker’s Compensation Coordinator.
- Look to receive a prescription payment card in the mail (it is supplied by Mitchell ScriptAdvisor). Use it for payment of medication directly related to your injury/ illness claim.
- If an injury will result in lost time from work:
- Notify your supervisor and campus Worker’s Compensation Coordinator.
- Provide your supervisor with medical documentation for the lost time injury.
- Report the lost time biweekly as directed by your supervisor or campus Worker’s Compensation Coordinator.
(i) Seeking treatment does not guarantee medical expense will be paid for through the worker’s compensation program. We would advise that you should stay within the confines of your own personal health insurance to ensure coverage in case the worker’s compensation program turns down the claim and does not pay it. The payment decision is made following an evaluation of the work-relatedness of the injury, and that the treatment relates to the work injury. Lack of complete medical documentation may result in delay of payments.
(ii) Choose a medical care provider licensed in Wisconsin. You may choose a second physician, but you may not be treated simultaneously by two providers. You may not seek a third provider unless referred by your primary provider. Doctors within a clinic are not considered a change of doctors.