Form to be filled out by supervisors
The injured employee's supervisor is to complete a First Report of Occupational Injury or Illness form. This is a legal document which will be filed with the Nebraska Worker's Compensation Court. Please print legibly and use the word "alleged" if there is any doubt that the accident happened at work, or there were no witnesses present. Mail or fax this form to the Benefits Office within 24 hours of the occurrence.
In the event that there is lost time (other than the day of injury), up to five instances of Injury leave can be granted if the employee provides a doctor's note stating that he or she is unable to come to work due to the injury. Injury leave is based on an employee's normal work hours. For example, if an employee normally works eight hours per day but was off of work due to an injury for four hours, then four hours would be recorded as Injury leave, and this would count as one instance. Five instances of injury leave are allowed, totaling up to 40 hours. For injuries that involve lost time beyond five working days, please contact the Benefits Office at 472-2600. If an employee has lost time, please send a copy of their time card to the Benefits Office.
For doctor's notes that outline restrictions (light duty), the decision falls to the supervisor to determine if they can accommodate the temporary restrictions. Upon receipt, supervisors need to fax or mail a copy of the doctor's note to the Benefits Office.
Forms to be filled out by injured employees
Please fill out the Worker's Compensation Incident Report and the Employee's Choice or Change of Doctor forms. These supplemental forms help our Worker's Compensation carrier gain a better understanding of the accident or injury. Once completed, please mail or fax the forms to the Benefits Office.
Form to be filled out by Attending Physician
Please have the doctor complete the Release to Return to Work form and submit the completed form to your supervisor upon your first day back to work.
If you have any questions regarding the process of filing a worker's compensation claim, please contact the Benefits Office at 472-2600.
32 Canfield Administration
University of Nebraska-Lincoln
Lincoln, NE 68588-0409
Campus Mailing Address
32 ADMN (0409)