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Worker's Compensation

Forms

  • Employees
    • What if you are injured at work?
    • What does worker’s compensation cover?
    • What is the impact on other benefits?
    • Lost time fact sheet
    • Limitations and denials
  • Supervisors
    • Before an injury or illness
    • After an injury or illness
  • Coordinators
    • Initial coordinator actions
    • Processing the claim
    • Enterprise database
    • OSHA recordkeeping
    • Cause code assistance
    • Training resources
  • Forms
  • Events
  • Contacts
    • Coordinators by institution
    • WC staff at UW System Admin.
  1. University of Wisconsin System
  2. Worker's Compensation
  3. Forms

Forms

Employees

Employee's work injury and illness report Employee's Work Injury And Illness Form pdf

Supervisors or Worker’s Compensation Coordinators

Employer's first report of injury or disease Employer's First Report of Injury or Disease pdf Employer's First Report of Injury or Disease (Word version) doc

Supervisors

Supervisor's Accident Analysis and Prevention Report

  • Supervisor's Accident Analysis and Evaluation of Repetitive Motion and/or Material Handling Activities pdf

Forms for Employees

  • Mileage Reimbursement Form docx
  • Part Time Labor Market Availability Statement doc
  • Voluntary And Informed Consent For Disclosure Of Health Care Information pdf

Forms for Safety Managers

Safety Manager Review docx

Forms for Worker’s Compensation Coordinators

  • Enterprise 17.1 Browser Requirements pdf
  • Enterprise Access Request And User Agreement doc
  • Early Return To Work Agreement doc
  • Return To Work Evaluation doc

 

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Worker's Compensation

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University of Wisconsin System
Office of Risk Management
Worker's Compensation

608.890.4792
608.263.7330
workcomp@uwsa.edu

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