Workers Compensation Forms

Incident Report

• Use this form to fill out details of the incident.
• Both the supervisor and the employee need to fill out their sections and sign.
• When the employee reports their injury on the RSS site, they will upload the incident report on the final screen with the DWC-1.

DWC-1

• The employee must fill this out before receiving treatment for their worker's compensation injury.
• Please upload the completed form to RSS site, in the final screen of the self reporting module.
• The employee must take this with them when receiving care at Patients First. 

Risk and Safety Solutions (RSS) portal

• The online platform used to submit worker's compensation claims 

Notice to Employees

• English
• Spanish

Time of Hire Notice 

• English

Pharmacy Benefit Network Brochure

• English
• Spanish

Pharmacy Benefit Network Poster 

• English
• Spanish

Pre-Designation of Personal Physician Form

An employee uses this form to designate their personal physician to provide treatment in the event of a work-incurred injury or illness. 

• Predesignation of Personal Physician

TRTW - Supervisor Information Sheet  

• Supervisor information regarding the transitional return to work process.

TRTW - Employee Information Sheet

• Employee information regarding the transitional return to work process. 

TRTW - Plan Agreement

• The form that the benefits analyst will use to facilitate the transitional return to work procedure. This is implemented when an employee has work restrictions that can be accommodated for a specific amount of time by the department.

Work Status Report

•  Treating Facilities usually provide their versions of a work status

Workers Comp Election Form  

• Provided to the employee if they need to go on leave due to their department not being able to accommodate their workers compensation work restrictions outlined by the Work Status Report.