Workers' Compensation Forms
Forms available are created in PDF formats, which require Adobe Acrobat Reader to display. If you do not have this product, please click on the Adobe icon below to install a free copy:
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. In the event of a non-life threatening injury, employees are to 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 Human Resources 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. Click here for the List of Panel Doctors.
The forms listed below should be completed promptly and returned to Human Resources, Haas Building, 3rd Floor. Please call with any questions: (484) 664-3165 or Ext. 3165.
Forms to be Completed by the Employee:
- Employee Injury Report
- Incident Investigation Report
- Consent Form
- Notice of Rights and Duties
- Worker's Compensation Information
- Authorization to Release Medical InformationForms to be Completed by the Supervisor:Forms to be Completed by the Physician: