UW System Home > Safety & Loss Prevention

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.

• Authorization for Release of Medical Records
• 3 Point Contact
• Carpal Tunnel Syndrome Claim
• Employment Records Release
• Supervisor's Accident Analysis and Prevention Report and Supervisor's Evaluation of Repetitive Motion and/or Material Handling Activities
  • pdf format
• Labor Market Availability Restriction Statement (11/22/10)
  • pdf format
• Return to Work Evaluation
• Repetitive Motion Injury
• Employee's Work Injury and Illness Report
  • pdf format
• WKC-12: Employer's First Report of Injury or Disease (1/21/10)
• WKC-13: Supplementary Report on Accidents and Injury or Disease
• WKC-13-A: Wage Information Supplement
• Physician's Certification Form
• Sample Initial Doctor Contact Letter for the Physician's Certification Form
• Safety Coordinator's Review
• Mileage Reimbursement Form