List of forms and helpful links
- Employee's First Report of Injury form
- Supervisor Report
- Worker's Compensation Provider Letter
- Colorado Department of Labor and Employment Workers' Compensation
- Pinnacol Assurance Employee Resources
- DU Board Approved Workers' Compensation Policy
To report a work related injury the EMPLOYEE should complete the Employee’s First Report of Injury Form. The supervisor should complete this form only if the employee is unable. The original copy should be given to your supervisor.
As the supervisor of an injured employee:
- You should fax the Employee First Report of Injury along with the completed Supervisor Report within 24 hours to Risk Management.
- You should conduct a thorough investigation of the injury using the Supervisor Report to determine if it could have been prevented, if additional training is necessary, etc.
- The Supervisor shall provide the WC Provider Choice Letter at the time of the injury, unless it is a life threatening/serious injury.
What is accident investigation?
The process of examining every factor of an incident in detail to determine the root cause(s). Root causes are contributing factors/events (acts and conditions) that may cause incidents.
Will the injured employee be drug tested?
Please see the current Human Resources policy.
Why conduct accident investigations?
- It is one of the best ways to prevent future incidents of the same nature.
- Reduce employee lost time due to injuries and provide a safe work environment for employees.
What is NOT part of accident investigation?
- Accident investigation is NOT used to determine blame or fault.
How should the Supervisor Report be completed and what should be considered?
- What are the causes of the incident (e.g. equipment, environment, people/behavior, materials)?
- Why did the incident occur according to the FACTS?
- Does this employee need re-training? If so, what kind?
- What could have been done to prevent the incident?
- Was the incident caused by any unsafe acts or conditions?
- What action is recommended to prevent recurrence?
- When evaluating, keep asking why, dig deep, for example: An employee fell on the stairs. Why? Were the stairs wet, damaged, lighting was poor, etc.
Workers' Compensation Provider Choice Letter
The University of Denver has designated two medical providers to treat employees injured on the job per House Bill 1176, the Employee Choice of Physician law.
Steps for completing the Provider Choice Letter process:
- At the time of an employees’ injury the supervisor shall print 2 copies of the Workers' Compensation Provider Choice Letter.
- One copy should be signed and dated by the employee and returned to the supervisor.
- The supervisor should then send the signed and dated form within 24 hours to Risk Management at firstname.lastname@example.org or 303-871-4455.
- The second copy is to be given to the employee who should retain it for their records.
- In addition, the supervisor should document the date the letter was provided to the employee on the Supervisor Report.
What else do you need to know about the Employee Choice of Physician law?
- If circumstances prevent providing the WC Provider Choice Letter at the time of injury, the letter must be provided by verifiable means within seven (7) business days of the injury notification date.
- An injured employee has the right to make a one-time change between the two medical providers by giving notice within 90 days of the injury, but before he/she reaches maximum medical improvement (MMI).
- The injured employee must request the change of medical provider in writing by submitting an approved Division of Workers’ Compensation form to the following parties:
- The current treating physician
- The requesting treating physician (this physician must be on the employer’s designated provider list)
- Risk Management
- Pinnacol Assurance, the University’s WC insurance provider