Forms to be filled out by supervisors
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 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. Send this form to the campus Worker's 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 at 402-472-8641. If an employee has lost time, please send a copy of their time card to the campus Worker's 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 Worker's Comp Administrator.
Forms to be filled out by injured employees
- Worker's Compensation Incident Report
- 7 Day Waiting Period Acknowledgement
- Employee's Choice or Change of Doctor
Please fill out the Worker's Compensation Incident Report, 7 Day Waiting Period Acknowledgement 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 fax or e-mail the forms to the campus Worker's Comp Administrator.
Form to be filled out by Attending Physician
If you have any questions regarding the process of filing a worker's compensation claim, please contact the campus Worker's Comp Administrator at 402-472-8641.
Here are other various forms potentially needed to complete filing a worker's compensation claim.
- Employee Mileage Form
- First Script Workers Compensation Program (en español)
- HIPPA Compliant Release (Benefits Office Use Only)
- Witness Statement Form
If you have any questions regarding the process of filing a worker's compensation claim, please contact the campus Worker's Comp Administrator at 402-472-8641 .