Required Forms to File an Injury Claim
If you have any questions regarding the process of filing a workers compensation claim, please contact the campus Worker's Comp Administrator.Workers Comp Administrator
402-472-8414 | 402-472-6803 (fax)
To be completed by Supervisor
- First Report of Occupational Injury or Illness form: This asks for important information concerning the employee, employment status, and when and how the accident happened. (Complete only the Employee and Occurrence/Treatment sections.) Please leave the SSN blank.
- Supervisors Incident Analysis Report: This form requests information from the Supervisor on how the injury was caused and future prevention of the injury. Please leave the SSN blank.
The injured employee's supervisor is to complete the First Report of Occupational Injury or Illness form and the Supervisors Incident Analysis Report. These are legal documents 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 at work, or there were no witnesses present. Send this form to the campus Workers Comp Administrator via e-mail or fax within 24 hours of the occurrence.
In the event that there is lost time, 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 campus Worker's Comp Administrator. If an employee has lost time, please send a copy of their time card to the campus Workers Comp Administrator.
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 e-mail a copy of the doctor's note to the campus Workers Comp Administrator.
To be completed by Employee
- Employee Incident Report: This form requests more specific information on the injuries that the employee sustained.
- Employee's Choice or Change of Doctor: This form allows the employee to see a doctor of their choosing or if they need to change to a different doctor.
- 7 Day Waiting Period Acknowledgement: This form explains what to expect in the first 7 days/occurrences of missed work of a Workers Comp claim. This form must be completed and signed, even if the employee has not missed work.
- HIPAA Release Form: This gives permission for our Workers Compensation carrier to request records and speak to the treating doctor(s) about the employee’s work injury only. When completing the HIPAA Release form, leaving the section pictured below blank. When completing the HIPAA Release form, leaving the section pictured below and the SSN blank.
- Witness Statement Form: This form must be completed by anyone that may have witnessed the injury incident
Please fill out the Employee Incident Report, Employee's Choice or Change of Doctor, 7 Day Waiting Period Acknowledgement, HIPAA release Form, and Witness Statement Form. These supplemental forms help our Worker's Compensation carrier gain a better understanding of the accident or injury. Once completed, please fax or e-mail the forms to the campus Worker's Comp Administrator.
To be completed by Attending Physician
- Workability Form: 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.
Additional Forms and Information
Here are other various forms potentially needed to complete filing a worker's compensation claim.
- Check, Direct Deposit & Prepaid Card Authorization Form: There are several payment options that are available for your worker’s compensation claim. You can also learn about the prepaid card through USB ReliaCard, USB ReliaCard Pre-Acquisition Disclosure, ReliaCard Flyer, and ReliaCard FAQs.
- Mileage Reimbursement Form: Our Workers Compensation carrier may reimburse mileage to or from your appointments.
- MyMatrixx Workers Compensation Program: If the doctor you see for your worker's compensation injury gives you a prescription, follow the steps at the top of the page to enroll and take the form to the pharmacy. If you have already picked up a prescription, before receiving this MyMatrixx form, please send a copy of the receipts to the campus Workers Comp Administrator.
- GBGO App: You can access your workers comp claim on any smartphone.
If you have any questions regarding the process of filing a workers compensation claim, please contact the campus Workers Comp Administrator.