Required Reporting Forms

The injury packet forms should be completed and emailed to workerscompensation@uta.edu within 24 hours of the injury. If immediate medical treatment is required, these forms may be submitted as soon as practical after medical treatment has been provided.

The following forms are included in the injury packet:

• Notification of Work-Related Injury or Occupational Illness - Give to medical provider.
  
  
• Employee's Report of a Work-Related Injury or Occupational Disease - Complete and sign form as soon as possible after the injury.
  
  
• WC Network Acknowledgement form - Complete and sign. (Spanish/Vietnamese)
  
  
• Notice of Network Requirements for UT System - Please read. (Spanish/ Vietnamese)
  
  
• Supervisor's Report of Employee Work-Related Injury or Occupational Disease Complete and sign.
  
  
• Choose traditional prescription form or Text2Fill.
  
  
• WCI Employee's Leave Election - If one or more workdays are lost due to injury, complete and sign.
  
  
• Injury Leave for Peace Officers Only - Complete and sign.