Use this form to report employee* injury during job performance.
A copy of the completed form is automatically submitted to Risk Management for processing, to assigned Department/Division staff and the employee's direct Supervisor for safety measurement and potential investigation and/or corrective action.
The Confirmation Page received by assigned staff includes fields to record other information collected about the injury and corrective action, if any/needed. If corrective action is identified, the form will be signed by the employee and Department/Division Manager or assigned staff and a copy placed in the employee's Human Resources file.
*Form not for use by Police and Fire.
Questions and Answers About Workers' Compensation Law For Injured Workers ( http://www.iowaworkforce.org/wc/qa14-15.pdf )
Powered By
Core Business Technologies