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Workers' Compensation Forms and Information

First Report of Injury Instructions

When an employee notifies you that an injury has occurred, it is your department’s responsibility to obtain all pertinent information needed for completion of the injury report. The injury must be reported to Human Resources within 24 hours.

Quick Guide 

1) The department will need to give the injured employee the Kentucky Brickstreet Injury Kit Packet and have the required forms completed, which are:
   • Medical Waiver and Consent Form(Scan or fax to 3464 HR with employee/student worker signature)
   • Physician Statement of Physical Capabilities (The healthcare provider is required to complete this form at the initial appointment and the employee must return it to Human Resources)
   • Notice of Designated Physician(Scan or fax to 3464 HR with employee/student worker signature)

2) The department will need to complete the First Report of Injury or Illness with all of the pertinent information immediately, but no later than 24 hours after the injury is reported. All questions relating to the accident must have detailed answers. (email the form without social security number within 24 hours).

If the injury occurs during the second or third shift or on the weekend, the injury must be reported at the beginning of the next working day. A delay in reporting an injury has the potential for denial of coverage. 

It is very important that the above information and other related information (medical bills, disability statements, doctors’ reports, etc.) be submitted quickly to avoid denial of workers’ compensation benefits.

We appreciate your assistance in helping us process workers’ compensation claims. If you have any questions concerning these procedures or forms, please call Human Resources at 2146.


Modified 9/21/2018
Article ID: 676