{"id":36,"date":"2014-06-03T14:20:06","date_gmt":"2014-06-03T19:20:06","guid":{"rendered":"https:\/\/www.wisconsin.edu\/workers-compensation\/?page_id=36"},"modified":"2024-07-19T13:20:21","modified_gmt":"2024-07-19T18:20:21","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.wisconsin.edu\/workers-compensation\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"\n\t\t\t\t\t<div id=\"cfct-build-36\" class=\"cfct-build grid\">\n\t\t\t\t\t\t<div class=\"row\"><div class=\"col-md-4 cfct-block\">\n\t\t\t<div class=\"cfct-module uwsa-callout\">\n\t\t\t\t<div class=\"cfct-mod-content callout standard grey-bg\">\n    <h3 class=\"cfct-mod-title\">Employee's Work Injury and Illness Report<\/h3><p>Please complete the report before your shift ends or within 24 hours of the incident.\u00a0<\/p>\n<p><a class=\"btn btn-primary btn-sm \" role=\"button\" href=\"https:\/\/wayf.wisconsin.edu\/DS\/WAYF?entityID=https%3A%2F%2Fuwss.bplogix.net%2F&#038;return=https%3A%2F%2Fuwss.bplogix.net%2Flogin_saml.aspx%3Fbp_nextpage=https%253A%252F%252Fuwss.bplogix.net%252Fform.aspx%253Fpid%253De6634b2b-e441-4279-8c38-a89adb52152c%2526formid%253Dcfdbd0a5-d1c2-4e83-9ccc-c8d80fb9c0e8%2526nohome%253D0%2526completepageprompt%253D0%2526completepage%253D%2526completetext%253D&#038;returnIDParam=campus\">Click here to report an incident<\/a><\/p><\/div>\n\n\t\t\t<\/div><\/div><div class=\"col-md-4 cfct-block\">\n\t\t\t<div class=\"cfct-module uwsa-callout\">\n\t\t\t\t<div class=\"cfct-mod-content callout standard grey-bg\">\n    <h3 class=\"cfct-mod-title\">Supervisor's Incident Analysis and Prevention Report<\/h3><p>Please complete the report within 24 hours of notice of the incident.<\/p>\n<p><a class=\"btn btn-primary btn-sm \" role=\"button\" href=\"https:\/\/uwss.bplogix.net\/form.aspx?pid=e6634b2b-e441-4279-8c38-a89adb52152c&#038;formid=51e98b88-1288-419b-95c0-a36165b2a551&#038;nohome=0&#038;completepageprompt=0&#038;completepage=&#038;completetext=\">Click here to report an incident<\/a><\/p><\/div>\n\n\t\t\t<\/div><\/div><div class=\"col-md-4 cfct-block\">\n\t\t\t<div class=\"cfct-module uwsa-callout\">\n\t\t\t\t<div class=\"cfct-mod-content callout standard grey-bg\">\n    <h3 class=\"cfct-mod-title\">Safety Manager Review<\/h3><p>Please complete the Safety Manager&#8217;s Review within 48 hours of being notified of an incident.<\/p>\n<p><a class=\"btn btn-primary btn-sm \" role=\"button\" href=\"https:\/\/uwss.bplogix.net\/form.aspx?pid=e6634b2b-e441-4279-8c38-a89adb52152c&#038;formid=cbf08349-1c2c-4d30-85ae-b642fb0324dd\">Click here to submit your investigation.<\/a><\/p><\/div>\n\n\t\t\t<\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-12 cfct-block\">\n\t\t\t<div class=\"cfct-module uwsa-rich-text\">\n\t\t\t\t<div class=\"cfct-mod-content copy\"><h2>Forms for Employees<\/h2>\n<div class=\"doc-list\">\r\n<ul class=\"list-unstyled\"><li><span class=\"doc-icon\"><a class=\"doc-type pdf\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/new_ee_injury_form\/Employee-Work-Injury-and-Illness-Report.pdf\" target=\"_blank\">Employee's Work Injury And Illness Form<span class=\"sr-only\"> pdf<\/span><\/a><\/span><\/li>\r\n<li><span class=\"doc-icon\"><a class=\"doc-type docx\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/additional_ee_forms\/UW-MILEAGE-REIMBURSEMENT-2019.docx\" target=\"_blank\">Mileage Reimbursement Form<span class=\"sr-only\"> docx<\/span><\/a><\/span><\/li>\r\n<li><span class=\"doc-icon\"><a class=\"doc-type doc\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/additional_ee_forms\/Part%20Time%20Labor%20Market%20Availability%20Statement.doc\" target=\"_blank\">Part Time Labor Market Availability Statement<span class=\"sr-only\"> doc<\/span><\/a><\/span><\/li>\r\n<li><span class=\"doc-icon\"><a class=\"doc-type pdf\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/additional_ee_forms\/Voluntary-and-Informed-Consent-for-Disclosure-of-Health-Care-Information.pdf\" target=\"_blank\">Voluntary And Informed Consent For Disclosure Of Health Care Information<span class=\"sr-only\"> pdf<\/span><\/a><\/span><\/li>\r\n<\/div>\n<h2>Forms for Supervisors<\/h2>\n<div class=\"doc-list\">\r\n<ul class=\"list-unstyled\"><li><span class=\"doc-icon\"><a class=\"doc-type pdf\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/supervisor_forms\/Supervisor-Incident-Analysis-and-Prevention-Report1.pdf\" target=\"_blank\">Supervisor's Incident Analysis and Prevention Report<span class=\"sr-only\"> pdf<\/span><\/a><\/span><\/li>\r\n<\/div>\n<h2>Forms for Safety Managers<\/h2>\n<span class=\"doc-icon\"><a class=\"doc-type docx\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/Safety-Manager-Review-template-1.17.2018.docx\" target=\"_blank\">Safety Manager Review<span class=\"sr-only\"> docx<\/span><\/a><\/span>\r\n\n<h2>Forms for Worker&#8217;s Compensation Coordinators<\/h2>\n<div class=\"doc-list\">\r\n<ul class=\"list-unstyled\"><li><span class=\"doc-icon\"><a class=\"doc-type pdf\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/stars_access_forms\/End-User-System-Requirements-_17.1.0-ExternalUser.pdf\" target=\"_blank\">Enterprise 17.1 Browser Requirements<span class=\"sr-only\"> pdf<\/span><\/a><\/span><\/li>\r\n<li><span class=\"doc-icon\"><a class=\"doc-type doc\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/stars_access_forms\/DOA-6050-Riskonnect-ClearSight-Enterprise-Access-and-User-Agreement.doc\" target=\"_blank\">Enterprise Access Request And User Agreement<span class=\"sr-only\"> doc<\/span><\/a><\/span><\/li>\r\n<\/div>\n<div class=\"doc-list\">\r\n<ul class=\"list-unstyled\"><li><span class=\"doc-icon\"><a class=\"doc-type doc\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/return_to_work\/Early-Return-to-Work-Agreement.doc\" target=\"_blank\">Early Return To Work Agreement<span class=\"sr-only\"> doc<\/span><\/a><\/span><\/li>\r\n<li><span class=\"doc-icon\"><a class=\"doc-type doc\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/return_to_work\/Return-to-Work-Evaluation.doc\" target=\"_blank\">Return To Work Evaluation<span class=\"sr-only\"> doc<\/span><\/a><\/span><\/li>\r\n<\/div>\n<h2>Forms for Witnesses<\/h2>\n<span class=\"doc-icon\"><a class=\"doc-type pdf\" href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/Witness-Statement-Form.pdf\" target=\"_blank\">Witness Statement Form<span class=\"sr-only\"> pdf<\/span><\/a><\/span>\r\n\n<\/div>\n\t\t\t<\/div><\/div><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-36","page","type-page","status-publish","hentry","cfct-can-haz-build"],"_links":{"self":[{"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/pages\/36","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/comments?post=36"}],"version-history":[{"count":14,"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/pages\/36\/revisions"}],"predecessor-version":[{"id":1288,"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/pages\/36\/revisions\/1288"}],"wp:attachment":[{"href":"https:\/\/www.wisconsin.edu\/workers-compensation\/wp-json\/wp\/v2\/media?parent=36"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}