As a supervisor, you are responsible for completing appropriate Work Comp paperwork with the employee and submitting the forms to Human Resources within 24 hours of the incident.
Below is a checklist that you should follow in the event that an employee notifies you of an injury that occurred on the job:
- Provide employee with a copy of the Workers’ Compensation Information and Privacy Statement Form (pdf) and ask them to review and sign the statement. Send the signed form to HR.
- Provide employee with Employee Statement regarding Injury/Illness/Incident Form (Word Doc) with instructions to complete the statement. Completed forms should be delivered to HR within 24 hours.
- Complete Incident/Injury/Illness Data Form (Word Doc) (IDF, this form replaces the First Report of Injury form) with employee and submit to HR within 24 hours of the incident.
- Complete Agency Claims Investigation Form (Word Doc) and submit to HR within 24 hours of the incident.
- Provide employee with the Leave Supplement Form (pdf) and ask them to review, select an option, and sign the statement (complete even if employee is not missing work at this time to document their intention should they begin to miss work). Submit the completed form to HR within 24 hours of the incident.
- Provide the employee with Workers’ Compensation Employee Information Packet (pdf). Review the documents with the employee to ensure a clear understanding of the process. The packet includes the following documents:
- Employee Information Packet introduction
- Notice of Enrollment in a Certified Managed Care Plan
- CorVel Managed Care Plan Instruction Brochure
- CorVel Managed Care ID Card
- CorCareRX Pharmacy Benefit
- Report of Work Ability form
- Provide employee with CorVel RX First Fill Prescription Information Sheet (pdf) to be taken to the pharmacy.
- Direct the Employee to Winona Health in Winona or Olmsted Medical Center in Rochester. If emergency services are required, direct employee to nearest emergency room.
- Inform HR if an employee seeks medical attention for a potential work related injury or illness or is expected to miss work due to the injury or illness.
- Contact CorVel’s 24 hour Nurseline at 1.866.399.8541 if the injured employee is treated in an emergency room, is admitted to an overnight stay at the hospital or requires immediate surgery.
- Document all witness statements and contact information, specifically name and phone number
- Secure and isolate any equipment that many have contributed to the injury.
- Obtain a copy of the Report of Work Ability Form (pdf) from the injured employee if they sought medical attention for the injury.
- For student worker injuries, also complete a Non-SEMA4 Employee Details Form (Word Doc) and deliver to HR within 24 hours.
*Please note that in the event of a medical emergency, call 911 or follow WSU’s emergency medical response procedures.