Safety & Loss Prevention
Worker's Compensation Forms
This page contains links to Worker's Compensation forms. Some of the forms are available in (PDF) format. Adobe Acrobat can be downloaded for free.
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Authorization for Release of Medical Records
- 3 Point Contact
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Carpal Tunnel Syndrome Claim
- Employment Records Release
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Supervisor's Accident Analysis and Prevention
Report and Supervisor's Evaluation of Repetitive Motion and/or Material
Handling Activities
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Labor Market Availability Restriction Statement (11/22/10)
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Return to Work Evaluation
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Repetitive Motion Injury
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Employee's Work Injury and Illness
Report
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WKC-12: Employer's First Report of Injury
or Disease (1/21/10)
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WKC-13: Supplementary Report on Accidents
and Injury or Disease
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WKC-13-A: Wage Information Supplement
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Physician's Certification Form
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Sample Initial Doctor Contact Letter for the
Physician's Certification Form
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Safety Coordinator's Review
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Mileage Reimbursement Form