The Workers Compensation program covers all employees of the university, including student workers. The coverage is for injuries arising out of and in the course of a person's employment. Workers Compensation pays the employee's medical bills and, if the employee is off more than five (5) days, Workers Compensation will pay 2/3 of the person's wages up to a statutory maximum. Human Resource policy allows an employee up to five (5) days of injury leave based on the normal hours the person worked. This can be used as long as there is a note from a healthcare provider stating the employee should be off work.
Work-related accidents should be reported to the Risk Management Office immediately.
Risk Management
📞 402.472.8414
📠 402.472.6803 (fax)
workerscomp@unl.edu
To be completed by Supervisor
- First Report of Occupational Injury or Illness: 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 UNL Risk Management via e-mail or fax within 24 hours of the occurrence.
Under Nebraska State law, the State is not required to compensate an employee for any time they are unable to work during the first seven days after a work-related injury or illness. However, the university provides injury leave at full pay up to 40 hours or five instances. The employee must proved a note from their healthcare provider stating that they are unable to come to work due to the injury.
For notes from the employee’s healthcare provider that outline restrictions (light duty), the decision falls to the supervisor to determine if they can accommodate the temporary restrictions. Supervisors may work with HR Employee Relations to find appropriate accommodation. Upon receipt, supervisors need to fax or email a copy of the doctor's note to UNL Risk Management.
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.
- Witness Statement: This form must be completed by anyone that may have witnessed the injury incident
- HIPAA Release: 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. (Only required if medical treatment was provided.) When completing the HIPAA Release form, leaving the section pictured below blank.
Please fill out the forms to help our Workers Compensation carrier gain a better understanding of the accident or injury. Once completed, please fax or e-mail the forms to UNL Risk Management.
To be completed by Attending Physician
Release to Return to Work: 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.
Forms and Information
Here are other various forms potentially needed to complete filing a worker's compensation claim.
- Check, Direct Deposit & Prepaid Card Authorization: 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: 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.