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 Workers' Compensation Court. Please print legibly and use the word alleged if there is any doubt that the accident happened or there are no witnesses. 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 days 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 for a specific period of time. 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 but one day has been used. For injuries that involve lost time past five working days, please contact the Benefits office at 472-3101.

For 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 Workers' Compensation Incident Report and the Employee's Choice or Change of Doctor forms. These supplemental forms helps our Workers' Compensation carrier gain a beter 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.