Forms & Tools
These are standard forms used in the administration of the workers' compensation program. Although these documents may be printed and used as necessary, the structure of the forms should NOT be altered by the agency. Note that particular letters
should be sent with the forms.
The following forms should be used for employees who are covered by the 274 calendar days (nine months) injury leave provisions.
Initial Notice to Injured Employee
Ongoing Claim Management
- Checklist for Injury Leave: used as a tracking tool for the workers' compensation coordinator to ensure the appropriate letters have been sent and the appropriate steps have been taken on each claim.
The following forms should be used for employees who are still covered by the 12 months injury leave provisions.
- Rights & Duties Form: notifies employees of their rights and duties relating to workers' compensation and the use of a list of designated health care providers. It is provided to all new employees during orientation and at the time of injury.
- Workers' Compensation Information Form: notifies employees of the commonwealth's workers' compensation claims administrator and their workers' compensation coordinator. Provided to new employees and posted on bulletin boards.
Reporting an Injury
- Workers' Compensation Claim Form JPA-797: used by supervisors to report work-related injuries in agencies that cannot file claims via Employee Self-Service.
- Incident Investigation Form: sample form to conduct initial or follow-up incident investigations including completion instructions and suggested best practices. This can assist agencies in documenting incidents to determine contributing factors and ways to prevent similar incidents from recurring in the future. The form is completed by the supervisor when a work-related injury occurs or when an incident could have caused an injury.
- Incident Statement Form: used to obtain information from a witness to a work-related injury or incident.
Initial Notice to Injured Employee
- Rights & Duties Form: notifies employees of their rights and duties relating to workers' compensation. It is provided to employees at the time of injury if the employee is required to get treatment from a designated health care provider.
- Notice to Employees Work-Related Injury Leave Information: enclosed with all initial letters to employees when an injury occurs.
- Paid Injury Leave Supplement (PILS) Form: submitted to the Bureau of Commonwealth Payroll Operations to obtain the estimated biweekly amount of paid injury leave supplement an injured employee will receive if paid injury leave is selected. The estimate must be included on the Work-Related Injury Leave Election form sent to the employee.
- Work-Related Injury Leave Election Form: sent to the injured employee in order to elect the type(s) of leave to be used during their absence. Agency HR staff should complete the top portion being sure to include the estimated biweekly PILS amount.
- Designated Health Care Provider Lists: provides all of the designated health care providers for the treatment of injuries occurring after July 1, 2012.
- KeyScripts Temporary Card: provided to injured employees to fill prescriptions that are written by a panel doctor. Please note that the workers' compensation coordinator must first activate the card using the instructions provided.
- Managed Care Card: provided to every injured employee for presentation to health care provider who is treating the injury. This ensures that the health care provider has the information to correctly bill Inservco.
General Program Management