Human Resources Department

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Workers' Compensation Forms

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As an employee of Muhlenberg College, you are required to report an on-the-job injury or illness immediately, but in no case later than 24 hours after the incident, to your supervisor and Campus Safety & Security. A procedure has been established so that you will receive appropriate medical attention in the campus Health Center and, if necessary, referral to a physician. If the Health Center is closed you will receive instruction from a Campus Safety & Security representative. Your supervisor will submit an injury report to the Human Resources Office for any injury sustained on College property. Each supervisor is responsible for investigating accidents. Please refer to the Incident Analysis Review report as a guide.

The College uses a panel of physicians and other health care providers for all work related injuries. Employees must select a physician or other health care provider from the panel for treatment. In order to have medical treatment paid by the College's insurer, the employee must continue to visit the physician or other health care provider for 90 days, if treatment is needed.

The forms listed below should be completed promptly and returned to the Human Resources Office.

Employee Injury Report (to be completed by the employee)

Incident Investigation Report (to be completed by the employee)

Consent Form (to be completed by employee)

Incident Investigation Report (to be completed by the supervisor)

Notice of Rights and Duties (to be completed by the employee)

Worker's Compensation Information (to be completed by the employee)

Authorization to Release Medical Information (to be completed by the employee)

Physician's Visit Report (to be completed by the physician)

List of Panel Doctors