Forms

First Report of Injury Form

All accidents and injuries occurring at work or in the course of employment must be reported to the employee's supervisor as soon as possible, even if no medical attention is required. The supervisor and/or employee are responsible for completing a First Report of Injury (FROI) within 24 hours of the incident. 

Benefit Election P-28

After an employee has missed more than three calendar days, they will receive a workers’ compensation benefit election questionnaire in their Workday inbox.

Express Scripts Temporary Card

A temporary card issued to the employee by Sedgwick CMS allows the employee to fill his or her prescriptions during the time that he/she is eligible for workers’ compensation benefits. This card is sent to the employee with a letter that contains instructions about its use.

Mileage/Prescription Expense Reimbursement

This form is provided to the employee for reimbursement of expenses related to the injury or illness specified on the First Report of Injury. The third-party administrator, Sedgwick CMS, will review requests for mileage reimbursement for mileage accrued traveling to and from appointments. Mileage reimbursement forms are available online or by contacting University Human Resources at 515-294-8917. The completed form may be sent by mail to 3210 Beardshear Hall or sent directly to Sedgwick CMS, P.O. Box 14628, Lexington, KY 40512.

Mileage/Prescription Reimbursement Form

Work Status Report

Employees with work-related injuries must provide their supervisor with a Work Status Report completed/signed by the treating physician within one (1) business day of each medical appointment. Supervisors have a responsibility to review this document and consider all restrictions given by the physician when assigning work to the employee. Whenever possible, reasonable accommodations will be implemented to assist the employee in a timely and appropriate return to work. Supervisors must forward copies of all Work Status Reports to the Workers' Compensation office as soon as possible.

Return To Work/Transitional Employment

When a department is accommodating multiple restrictions for an employee, a Transitional Employment Plan is prepared and reviewed by the medical provider. This document clarifies indicated medical restrictions/limitation, reasonable accommodations, etc. and identifies the duration of these temporary arrangements. Transitional Employment Plans are not permanent changes in job duties, but are considered temporary (short term until maximum healing is reached.)

Transitional Work Plan Form

Lost and Restricted Time Report

Lost and restricted time must be reported for each employee who has missed work or been restricted from performing one or more of his/her routine job tasks (job functions performed at least once per week) due to a work-related injury or illness. The Lost and Restricted Time Report is to be completed by the supervisor/manager by responding to the weekly reminder email.

Recording lost or restricted work hours for employees with a work-related injury:

  • Injured/ill employee is paid by ISU a full day of pay on the day of injury (regardless of what time they leave work) and no vacation or sick leave is used.
  • Date of injury is not counted as part of the three-day waiting period.
  • The definition of the three-day waiting period is "three calendar days of full or partial incapacity" (Iowa Code 85.27). Time missed must be physician-directed for the employee as follows:
    • may not return to work
    • off work a portion of the day, along with work with specific restrictions for work duties for a portion of the day restricted length of work time