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Worker's Compensation - Forms, Documents & Info:

Worker’s Compensation is a disability program that pays benefits when you have sustained a work-related accident or injury as defined in the Wisconsin Statutes. At the time of the injury there must be an employee-employer relationship. An employee-employer relationship exists when you perform services for your employer. To be eligible for benefits, your injury or occupational illness must have occurred in the performance of these services.

If it is an emergency, do not hesitate to go to the emergency room.

The following steps should be taken when a faculty, staff member or student worker is injured while performing job responsibilities:

IMPORTANT: If the injured employee misses any work time, the injury/incident must be reported to Human Resources within 24 hours of the injury/incident. If no time from work is missed, the forms must be received in Human Resources within 3 days of the incident.

Employees

It is your responsibility to report the injury to the supervisor on duty the day/time the injury occurs.
The Employee injured should complete the Workers Compensation: Employee's Accident Report  and submit it to his or her chair/supervisor.

Supervisors

It is your responsibility to ensure that the Employee's First Report AND the Supervisor Analysis and questions are given priority when an injury occurs.

The Chair/Supervisor must complete the Workers Compensation: Supervisor's Accident Analysis and Prevention Report and the Workers Compensation: Supervisor Questions Form.

Send both signed and dated forms, along with answers to the supervisor questions, to Human Resources, Tallent Hall 202, within 3 days of the injury. If need be, fax the paperwork to 262-595-2693 before sending originals to Human Resources.
If it is a work related death please contact Human Resources immediately. It must be reported to the Department of Workforce Development within 24 hours.

NOTE: Please complete the forms as thoroughly as possible to avoid delays in processing.

All Physician Return to Work forms and reports should be forwarded to Human Resources upon receipt.

These forms will indicate the date a faculty/staff member may return to work with or without restrictions and must be filed with Human Resources. For each physician visit, a return to work form should be submitted including if the diagnosis is to return to work with no restrictions.

Timecard/Leave Reporting should indicate any lost time due to a work related injury.
If lost time occurs, it is important that the timecard/leave report indicate those days off of work.

If, due to the injury, the chair/supervisor or employee are unable to complete the forms within the 3 days immediately contact Human Resources 262-595-2204 with the details of the injury.

The UW System Worker's Compensation Coordinator will contact the employee injured with details of the claim.

Important Note: Worker’s Compensation may offset payments from other benefit plans that you may be eligible for, such as Income Continuation Insurance and Social Security Disability

Related Links:

State of Wisconsin Department of Workforce Development

http://www.dwd.state.wi.us/wc/

Forms/Documents:

  1. Worker's Compensation: Absence Report Form

  2. Worker's Compensation: Employee's Accident Report

  3. Worker's Compensation: Supervisor's Accident Analysis and Prevention Report

  4. Worker's Compensation: Supervisor Questions Form

  5. Worker's Compensation: Medical Authorization (HIPAA Compliant)

  6. Worker's Compensation: Mileage Record

Contact:

For more information, or in case of an emergency, please contact:

Rita Altmeyer

ph. 262.595.2272

email: altmeyer@uwp.edu