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Workers' Compensation Alaska Statute, Title 23, Labor & Workers' Compensation |
Employees who are injured on the job and seek medical treatment and/or have time loss from work you may be eligible for Worker's Compensation coverage and benefits. If this has occurred, fill out the Report of Occupational Injury and Illness Report. For blank forms contact Environmental Health, Safety, and Risk Management at 474-5413.
HOW TO FILL OUT THE OCCUPATIONAL INJURY AND ILLNESS REPORT
Questions 1 - 17 are to be filled out by the employee who sustained the injury or illness.
| Question 2 | Home phone number |
| Question 6 | Home address |
| Question 11 | If you go to the Dr. please put full name and address of attending physician. |
| Question 14 | Type of injury. What is wrong? example - cut on right hand, index finger. |
| Question 15 | Describe what happened. Example - I was opening a cardboard box with a single blade knife when the box slipped off the table, the knife cut the index finger on my right hand. (Explain what you were doing and a little bit about how the accident occurred.) |
| Question 16 | Remember to sign and date the form. |
Questions 18 - 49 are to be filled out by the employees supervisor.
| Question 18 | Answer here should be: UAF/the department you work for. Example: UAF/Environmental Health & Safety |
| Question 19 | Leave blank |
| Question 20 | Address of your department |
| Question 21 | Answer here should be: Self Insured |
| Question 22 | Answer here should be: UA Statewide Risk Management PO Box 755240 Fairbanks, AK 99775 450-8150 |
| Question 23 | Date supervisor first knew of injury or illness |
| Question 38 | The supervisor should fill out this section. In the past the employee has been filling out this section. The supervisor should enter an explanation, not the employee who was injured. |
| Question 47 | Remember to sign and date the form. |
All other questions not covered individually above are "self explanatory"; however, if you have any questions, please contact Annette Chism at 474-6164 or Yvonne Boyce at 450-8152. If an injury or illness has occurred and you don't have the form, contact Environmental Health, Safety, and Risk Management, 474-5413, and the form will be put in inter-campus mail.
Report of Occupational Injury or Illness
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Copy
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Mail To
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| Blue Copy |
Alaska Worker's Compensation Board P O Box 25512 Juneau, Alaska 99802-5512 |
| White Copy |
UA Statewide Risk Management, Box 755240 |
| Pink Copy | Environmental Health, Safety, and Risk Management, Box 758145 |
| Yellow Copy | Employee |
| Green Copy | Employee |
It is the responsibility of the department to send the form to the appropriate address. The Environmental Health, Safety, and Risk Management department will not forward forms to the Worker's Compensation Board or to Statewide Risk Management.
OVERNIGHT HOSPITALIZATION OR DEATH:
If an injury or illness results in overnight hospitalization or death, notification by the employees supervisor must be made to the Environmental Health, Safety, and Risk Management department at 474-5413, within 8 hours of the incident. If the incident occurs after hours, holidays, or on the weekend, contact the UAF Emergency Dispatch center at 474-7721. Information the supervisor making the call will need at the time of call is: Employees name who was injured, birth date, date of injury, hospital name and a brief description of what happened.
WORKERS' COMPENSATION CONTACT INFORMATION
It is VITAL that all information pertaining to an occupational injury or illness be processed properly and in a timely manner. If you, as an employee or supervisor have any questions regarding procedure, the contact list below will be your guide to finding answers to your questions. Please do not hesitate to contact the people on the list.
| Environmental Health, Safety, and Risk Management Department |
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| Office of Statewide Risk Management | Director: Julie Baecker, snjcp@alaska.edu
or 450-8153 Risk Management Analyst: Carla Yurkovich, sncly1@alaska.edu or 450-8157 Claims Adjuster: Yvonne Boyce, yvonne.boyce@alaska.edu or 450-8152 Claims Technician: Amaya Spencer, amaya.spencer@alaska.edu or 450-8156 |
For further information on Workers' Compensation, UA Statewide Risk Management
Page last update on 10/10/06 by A.Chism