Workers’ Compensation Forms
Employee Incident Report Form
The employee incident report form is the employee’s opportunity to express the details surrounding his/her injury on the job. It gives the details in his/her own words and is often a good tool for corrective actions to prevent the injury from reccuring.
Supervisor’s Incident Investigation Form
The supervisor’s incident report form is the supervisor’s recollection of the details surrounding the employee’s injury on the job. The supervisor’s report will list any details that may correct the problem or to increase awareness in the department and the supervisor and employee.
Employer’s Report Of Employee’s Injury Or Occupational Disease (NCIC Form 19)
The employer’s report of employee’s injury or occupational disease to NCIC (NCIC Form 19) is the one that is used by the Industrial Commission when the injury occurrs on the job — this form includes many details necessary to the compensibility issue and the events which lead up to the inquiry — this form is absolutely mandatory in all cases of injuries on the job.
Note: Industrial Commission regulations require that the notification form be filed with the Industrial Commission within five days after the occurrence and knowledge on an injury; however, OSHA regulations require that injuries requiring medical treatment be recorded by the Environment, Health and Safety office within 48 hours. Therefore, it is imperative that injuries be reported to the Environment, Health and Safety Office as soon as possible.
Notice Of Accident To Employer And Claim Of Employee, Representative, Or Dependent For Workers’ Compensation Benefits (Form 18)
Form 18 with Instructions. These instructions were prepared by the Industrial Commission’s Ombudsman Section.
A Form 18 establishes a legal claim of injury on your behalf if filed within two years of the date of injury or occupational disease, and gives the required written notice to the employer if a copy is submitted to the employer within 30 days of the injury. In order to ensure the employee’s rights are protected, the employee must file a Form 18 even though the employer may be paying compensation or the Industrial Commission may have opened a file for the injury. The original Form 18 should be submitted to the Industrial Commission. The injured worker should keep one copy for his/her records and one copy should be submitted to whoever the employer was at the time of the injury.
Note: (G.S. §97-22 through G.S. §97-24). Revised February 2001.
Workers’ Compensation Leave Option (HR-28)
The workers’ compensation leave option form HR-28.