Worker's Compensation Injury Report

UW Safety Office

The "Workers Compensation Report of Injury" form must be completed.

Once completed, sign the Employee Certification section (the form may be completed electronically or on paper, but must be printed and signed). Submit the completed form to your Supervisor or other person authorized by your department to sign the Employer Certification.

Do not wait to turn in the form. If your supervisor is not available, please submit the form to Human Resources.

If you need assistance call Kira Poulson, 307-766-4220.

If the work-related injury involves any of the following, a "UW First Report of Accident/Incident" must also be completed.

• a motor vehicle being used for university business

• damage to university property

• injury to a third party