Workers’ compensation provides medical expenses, lost wages, and rehabilitation costs to employees who are injured or become ill “in the course and scope” of their job. It also pays death benefits to families of employees who are killed on the job.

Steps to report an employee injury/illness:

1. Employee must report any work-relate injury/illness to their Supervisor / Maintenance Department immediately.If working 2nd / 3rd shift must notify the next business day.

2. The employee must complete the first portion of the EACS employee work related injury/illness report form.

3. The Supervisor should complete the Indiana Worker’s Compensation First Report of Employee Injury/Illness.

4. The Supervisor will then give the employee a PVOH authorization form to be seen for treatment unless the injury/illness is emergent.If the employee must be transported by EMS please let Jennifer Rose know which hospital the employee is being transported to so that the hospital knows this is a work-related injury.

5. Complete the top portion of the EACS Accident Investigation form and give to the Building Administrator or Employee’s Supervisor.

6. If the employee refuses treatment or to complete the Indiana First Report of Injury/Illness (form 34401) please document this on the EACS employee work related injury/illness report form.

7. Please send ALL forms to Jennifer Rose at the Administration Building.

HC-First Report of Employee Injury Illness - Fillable(opens in a new window)

Medical authorization