This report must be submitted by e-mail within 24 hours of the incident to your campus Human Resources Department.
This report is to be completed electronically by the immediate supervisor, DOM, Division Coordinator, Department Assistant, Staff Assistant or Secretary. The signature can be done electronically.
This report is to be completed by the Employee. If the employee cannot complete this form immediately due to immediate medical reasons, please have the employee complete as soon as possible.
In order for the claims to be submitted to the correct address, this form will need to accompany the employee when he or she sees a doctor or the emergency room for a work-related incident. The bills should not be sent to your campus or to Health Select, but directly to the workers' comp carrier. Health Select will not pay for work related injuries.