Workers Comp. - For Employees: Forms for Employees

Forms for Employees

First Report of Injury Form

All accidents and injuries occurring at work or in the course of employment must be reported to the employee's supervisor as quickly as possible, even if no medical attention is required. The supervisor and/or employee are responsible for completing a First Report of Injury form and submitting this electronically via AccessPlus within 24 hours of the incident reporting.  Log into AccessPlus, then go to the Employee tab, select Work Injury and the select Continue to view the FROI home page in order to fill out the FROI form.  Employees can complete FROI's but supervisors must review, approve and electronically submit the form to University Human Resources.

Benefit Election P-28

After an employee has missed more than three calendar days, the supervisor mails or gives a copy to the employee of the letter referencing supplemental workers compensation benefits along with the Benefit Election P-28 form and requests that the form be completed and returned to the Workers' Compensation office as soon as possible.

Cover Letter

Word Form / PDF Form

Mileage/Prescription Expense Reimbursement

This form is provided to the employee for reimbursement of expenses related to the injury or illness specified on the First Report of Injury.  The third party administrator, Sedgwick CMS, will review requests for mileage reimbursement for mileage accrued traveling to and from appointments.  Mileage reimbursement forms are available online or by contacting the University Human Resources at 515-294-3753.  The completed form may be sent by mail to 3210 Beardshear Hall or sent directly to Sedgwick CMS, PO Box 14628, Lexington, KT 40512.

 Word Form / PDF Form

Work Status Report

Employees with work-related injuries must provide their supervisor with a Work Status Report completed/signed by the treating physician within 1 business day of each medical appointment. Supervisors have a responsibility to review this document and consider all restrictions given by the physician when assigning work to the employee. Whenever possible, reasonable accommodations will be implemented to assist the employee in a timely and appropriate return to work.  Supervisors must forward copies of all Work Status Reports to the Workers Compensation Office as quickly as possible.