Which form do I use to report a work-related injury?

Form 118 Medical only Injuries

It is the responsibility of the injured employee to report a work-related injury to his or her supervisor. The supervisor is responsible for filling out the correct form. The Form 118 is used for all medical only injuries as well as lost time cases resulting in less than 5 calendar days of incapacity. This completed form must be sent to the attention of Eileen Kaminsky of the Personnel Department. She in turn will send a copy to Risk Management and a copy to Cannon Cochran Management Services, the University's third party administrator.

Form 101 Lost Time Cases

The Form 101 should be filed for all lost time cases resulting in 5 or more calendar days of incapacity. It is important to count lost calendar days not lost work days. Send the original Form 101 to the Personnel Department who will forward this original to the Department of Industrial Accidents. A copy will also be sent to Risk Management and Cannon Cochran Management Services. Please note that there are strict reporting deadlines. The original Form 101 must be filed within 7 days from the fifth day of incapacity. The Department of Industrial Accidents will fine the University if a report is filed late.

How do I determine lost time?

In determining which form to complete, remember that you must count calendar days. For example, if an employee is injured on a Wednesday, and returns to work the following Wednesday, lost days would be counted as follows.

Thursday 1st day of incapacity
Friday 2nd day of incapacity
Saturday 3rd day of incapacity
Sunday 4th day of incapacity
Monday 5th day of incapacity
Tuesday 6th day of incapacity

Filing a Workers Compensation Claim

• It is very important to fill out report promptly. If filed late the University may face fines as well as employee's right to receive benefits may be jeopardized.
  
  
• Fill out the form as completely as possible. Missing information may cause the Department of Industrial Accidents to reject the form which could result in penalties.
  
  
• Be as specific as possible when describing how injury occurred, nature of injury and injured body part. This will help Risk Management and Cannon Cochran Management Services investigate the claim and make a fair determination of benefits.
  
  
• File every claim that is reported regardless of your opinion of the validity of the claim. It is the responsibility of the Office of Risk Management to determine the compensability of all claims.
  
  
• Employees may not file their own accident report. The supervisor must sign the form before sending it to the Personnel office.
  
  
• Remember to count calendar days, not work days.
  
  
• If a claim is accepted, related medical bills will also be covered by workers compensation.
  
  
• It is important to keep the lines of communication open between employee and employer. We urge supervisors to contact employees at home to express their concern for the employee's health and to let them know that the injured employee is a valuable part of the University.
  
  
• Sometimes an employee can not return to his or her full duties, however they are capable of some work capacity. We request that departments make reasonable accommodations that allow employees to return to modified work. The modified duty is usually only on a temporary basis and after a short period of time employee is able to resume full duties.
  
  
• We ask that departments keep the position of the injured worker open as long as possible. It is very unlikely that a judge at the Department of Industrial Accidents will terminate an employee's benefits if there is no job for which the employee to return.
  
  
• When an employee returns to work a supplemental Report of Injury should be completed and sent to Eileen Kaminsky.
  
  
• Benefits are calculated as 60% of the employee's Average Weekly Wage.
  
  
• Employees are billed for their share of their health plan, dental plan, etc. though the Benefits Department.
  
  
• Medical bills can not be paid unless either a form 118 or a form 101 is filled out.
  
  
• The University has established an Occupational Health Center (OHC) at 930 Commonwealth Ave. Injured employees that are seeking workers compensation indemnity benefits will be required to be evaluated at OHC before receiving benefits.