Workers' Compensation - Forms

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 then 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
PDF Form

Express Scripts Temp. Card

A temporary card issued to the employee by Sedgwick CMS. The card allows the employee to fill his or her prescriptions during the time that he/she is eligible for workers’ compensation benefits. This card is sent to the employee with a letter that contains instructions about its use.

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.

Mileage/Prescription Reimbursement 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.

Return To Work/Transitional Employment

When a department is accommodating multiple restrictions for an employee, a Transitional Employment Plan is prepared and reviewed by the medical provider. This document clarifies indicated medical restrictions/limitation, reasonable accommodations, etc. and identifies the duration of these temporary arrangements. Transitional employment assignment plans are not permanent changes in job duties, but temporary (short term until maximum healing is reached.)

Transitional Work Plan Form

Lost and Restricted Time Report

Lost and restricted time must be reported for each employee that has missed work or been restricted from performing one or more of his/her routine job tasks (job functions performed at least once per week) due to a work related injury or illness. The Lost and Restricted Time form is completed by the Supervisor/Manager via AccessPlus and submitted to the Workers' Compensation office by 5:00pm the Monday following each week for the duration of the recovery.

Employee Personnel Action (EPA) Form

All of the personnel actions listed below should be done according to the employee's pay status, i.e. every two weeks or on a monthly basis. An election form P-28 will be completed by the employee indicating:

  • Employee chooses to receive a check from workers compensation only.
  • Department should process a medical LWOP for the entire time period the employee is gone.
  • Employee chooses to supplement with their vacation, sick or comp time leave.
  • The adjusted leave amount will appear in a routed EPA from University Human Resources and will document workers’ compensation payment for the employee. The department follows-up with a corrected leave form when the employee has been gone more than 14 days; at that point workers’ compensation will reimburse the employee for the first 3 days. Those days should then reflect use of an adjusted rate instead of a whole day of vacation and sick leave use. (EPA Type of Action: W)
  • Employee comes back to restricted duty, but not for a full day and supplements.
  • The adjusted vacation, sick or comp time leave amount will appear in a routed EPA from University Human Resources and the department will modify the amount based on actual time worked.

Recording lost or restricted work hours for employees with a work related injury:

  • Injured/ill employee is paid by ISU a full day of pay on the day of injury (regardless of what time they leave work) and no vacation or sick leave is used.
  • Date of injury is not counted as part of the 3-day waiting period.
  • The definition of the 3-day waiting period is "3 calendar days of full or partial incapacity" (Iowa Code 85.27). Time missed must be physician directed for the employee as follows:
    • may not return to work
    • off work a portion of the day, along with work with specific restrictions for work duties for a portion of the day restricted length of work time