Forms
Following are examples of several forms (and directions when applicable) that you may need to complete when an injury occurs. If you have questions regarding the completion of any of these forms, contact your supervisor, your claims representative, or the University Workers’ Compensation Specialist in the Benefits Office at (319) 335-2676.
First Report of Injury Form – To be completed by the employee/supervisor on the Employee Self Service site under HR Applications within 24 hours of report of injury. Submitted by the University to appropriate parties documenting the work injury.
Missed Time Weekly Report – To be completed by designated departmental staff to report employee hours of work, and restricted work assignments/hours etc. If the employee will be missing at least a full day of work, the supervisor must notify Benefits within 24 hours of first absence, then weekly thereafter using the Missed Time Weekly Report. Form should be completed on the Employee Self Service site under HR Applications/Systems/Workers' Compensation.
Missed Time Benefit Election Form – To be completed by employee permitting/directing UI Benefits to supplement workers’ compensation benefits with accrued leave.
This report will be sent to the employee when it is reported to Workers' Compensation that the employee will (or has) missed 3 days of work.
Mileage Reimbursement Form – To be completed by the employee and submitted on a monthly basis to Sedgwick CMS for reimbursement of necessary travel expenses (ie. mileage, parking, etc.) related to a covered workers’ compensation claim. The employee is encouraged to keep a copy of this document for their records. Download form: pdf or word.doc
Restricted Work Assignment Form - To be completed by designated departmental staff and employee. Information outlines the restricted work assignment due to work-related illness/injury. Download form: pdf or word.doc
No Restricted Work Available Form - To be completed by department outlining that accommodations for current restrictions not available. Download form: pdf or word.doc
Questions? benefits@uiowa.edu