In the event of a work-related illness or injury both the employee and his/her supervisor have the responsibility to assure that complete and accurate information is conveyed to the University's Workers' Compensation Office and to Library Human Resources.  

If this information is not received, the Workers’ Compensation Office is unable to process any claim or provide any benefits.  The Department Report of Injury Form, ER 15-1 Rev. 1995 is the standard and exclusive method for reporting an on the job injury.

Prepared by Worker’ Compensation Office, Yale University and edited by Library Human Resources.

Department's Report of Injury
Supervisor's Responsibility

 The supervisor fills out a Department Report of Injury Form whenever an employee has or reports a work-related injury, accident or illness. Unless the accident has been witnessed by the supervisor, care must be taken to report in the third party by using words such as "employee states, claims, alleges", etc.

The form must be filled in its entirety. All information requested is necessary. Include information regarding current address and telephone number.

If the supervisor did not witness the accident, he/she should question the employee in person (or via telephone if this is not possible) to get the specific facts of the accident and injury and to fill out the Department Report of Injury.

If the supervisor has further information that he/she thinks is pertinent, that information should be added in the remarks section.

Upon completion of the Department Report of Injury, a copy of the report should be faxed immediately to the Workers' Compensation Office at 432-6241, as well as to Library Human Resources at 432-1806. Early notification assures prompt and effective medical treatment, case management and claim's determination. The report can then be sent to the Department Head for signature.

The report should now be burst and the original green copy forwarded to Workers' Compensation at 155 Whitney Ave. The second, yellow copy is retained for the department's records. The third, white copy is sent to the Office of Environmental Health & Safety, 135 College St., Attention: Safety Engineer.

The information contained in the Department Report of Injury is used to complete the mandated Workers' Compensation Commission of Connecticut Employer's First Report of Occupational Injury or Disease. 

All work-related injuries, accidents or illnesses must be reported to his/her supervisor by the employee. It is mandatory that this is done at the time of injury or, if illness, immediately when that illness is identified as being work related.  It is now the supervisor’s responsibility to complete the Department’s Report of Injury form. The employee should assure that the Department’s Report of Injury form is completed and faxed to the Workers’ Compensation office at 432-6241 and Library Human Resources at 432-1806.  

If medical treatment is needed after an injury an employee may choose a physician from the appropriate specialty listed in the Yale University Worker's Compensation Medical Directory or at Yale University Health Services.  

For treatment at Yale University Health Services for a work-related injury a Yale University Workers' Compensation Health Services Appointment and Report form must be presented. This form is obtained from the supervisor and is used at the first appointment and all following appointments. (This form is not used when treating with a physician outside of the University Health Services).

All employees are advised that if these instructions are not followed their claim for Workers' Compensation cannot be reviewed and they will not be entitled to Workers' Compensation benefits and can be held responsible for any expenses incurred.

In the case of an emergency, an employee may seek treatment at the nearest Emergency Care Facility.

Initial Treatment Centers have been designated as Yale University Health Services 17, Hillhouse Ave., New Haven, CT (203) 432-0246 or the Center for Orthopaedics (for musculoskeletal injuries only-neck, back, shoulder, arm, leg) and these appointments must be scheduled through the Workers’ Compensation Department at (203) 432-9830.  

In the case of non-emergencies, the employee may choose a physician from the appropriate specialty from the Yale University Workers’ Compensation Managed Care Plan Directory or go to the Yale University Health Services.  

If the employee chooses treatment by Yale University Health Services a Yale University Workers’ Compensation Appointment form must be presented at the time of care. This form is obtained from the employee’s supervisor.

The top section "request to Employee Health Services" is filled out, in its entirety, by the employee’s supervisor.

The remainder of this form is completed by personnel at University Health Services.

At the conclusion of the appointment the employee is given the pink or bottom copy to return to his/her supervisor.

The supervisor’s copy allows him/her to ascertain the employee’s work status (out of work, restricted duty or return to work). If restricted, a definition of the work restriction levels is on the reverse of the pink copy. If the supervisor is unable to provide work under these restrictions the supervisor must notify the Workers’ Compensation Office.

In the event the employee is taken out of work by UHS or the supervisor is unable to supply modified work, the employee must personally contact the Workers’ Compensation Office to assure benefits.

The Workers’ Compensation Office reviews its copy of this report to assure that this is an accepted Workers’ Compensation claim, to follow up on work availability in the event work restrictions have been changed, as notice of return to work and to assess comprehensiveness and appropriateness of care plan, diagnosis and length of disability.

The Accounting Copy is used by Yale University Health Services for billing purposes.