Workers' Compensation Forms

Claim Form (DWC-1)

Form to be used to report an injury or illness – required to be completed within 24 hours of injury or illness

Employee's Report of Work-Related Injury or Illness

Form to be completed by the employee to describe the circumstances surrounding the injury or illness.

Pre-Designation of Personal Physician

Form to be completed by an employee designating a personal physician to treat in the event of an injury or illness. Should be completed prior to any workers' compensation-related injuries or illnesses.

Supervisor's Report of Work-Related Injury or illness

Form to be completed by the supervisor describing the supervisor's understanding of the injury or illness.

Transitional Employment Plan

Form to be used when an employee returns from workers' compensation into a temporary and/or transitional job