Immediately provide as much information as you can about your injury or illness to your supervisor or departmental designee. This person will submit the requisite forms to Workers' Compensation to initiate your claim.

If you require medical treatment, follow the procedures set forth on the Health Care Provider Panel and Procedures - (Form C) for your campus.

Please sign the following Forms B and D:

• Workers' Compensation Information - (Form B)
• Employee Acknowledgement Revised 3/25/09 - (Form D)

Supervisor Responsibilities

• Departments should post the following forms in common areas: Remember: It Is Important To Tell Your Employer About Your Injury - (Form A), Health Care Provider Panel and Procedures - (Form C) for your campus and Employee Acknowledgement Revised 3/25/09 - (Form D).
• Have your employee sign both the Workers' Compensation Information - (Form B) and Employee Acknowledgement Revised 3/25/09 - (Form D). If an employee refuses to sign these documents, sign your own name and date that the employee has reviewed and understands the forms but refuses to sign.
• Fax the signed Workers' Compensation Information - (Form B), Employee Acknowledgement Revised 3/25/09 - (Form D) along with the completed two-page Employer's Report of Occupational Injury or Disease 1st page - (Form F), 2nd page - (Form G), and Additional Injury Report Information - (Form H) to Workers’ Compensation at 412-624-1817 within one business day of your knowledge of the incident.
• Provide a copy of the designated campus Health Care Provider Panel and Procedures - (Form C) to your employees and direct them to the Panel for treatment if they require medical attention.
• Immediately notify Workers' Compensation if an employee misses at least one day of work because of that injury.
• Immediately notify Workers' Compensation when an employee returns to work after a Workers' Compensation leave.