The procedures and forms below should be used when preparing and filing information regarding workplace injuries, illnesses, and incidents.
The following forms are to be completed and submitted to your agency Workers' Compensation Coordinator as soon as possible but no later than 24 hours after the incident. Please refer to the Supervisor's Checklist for more detailed information.
Note: When accessing Microsoft Word documents from your web browser, be sure to save a local copy to your computer or network drive before completing. Once completed, attach the document to an email or print it for sending. In most cases, Microsoft Word does not allow spell check within form fields so do your best and don't worry too much about spelling errors. With PDF forms, simply print the form, complete it by hand and route for distribution.
Further information about the workers' compensation process can be found in the Supervisor's Workers' Compensation Handbook (PDF).
Handling non-SEMA4 workers
The following two forms are to be completed by agency Workers' Compensation Coordinators for reporting work related injuries or illnesses involving employees that are not enrolled in SEMA4. Please complete the following forms and submit to the Workers' Compensation Program along with all forms indicated above.
If you have questions or need assistance related to preparing and filing the forms to report a possible work related injury or illness, or need help with workers' compensation claims management issues, please contact John Sargent via e-mail or at 651-201-3031.