Accident Forms

An Injury Report is to be completed for all injuries, even those for which the employee does not seek treatment. Complete the Injury Report form online and submit it electronically by clicking the 'submit' button in the form. The supervisor or employee should also contact the EHS Safety Specialist at 785-864-4089 or as soon as possible but no later than within 24 hours.

If property damage also occurred during the incident, please complete the Property Damage Report and submit it to the EHS Safety Specialist. The employee should also be given a WC-9 form to complete, which can be found under "Workers Compensation Forms" on the Kansas Adjutant General website. This can be submitted at the same time as the Injury Report, but if the employee has not completed the WC-9, do not wait to submit the Injury Report. If the employee completes it at a later time, he or she should send the WC-9 directly to the State Self-Insurance Fund at the address listed on the form.

If the injury occurs during normal business hours, is not severe in nature, as determined by the employee, and the injured employee wants to seek medical treatment, the injured employee's supervisor and/or the injured employee and the supervisor should contact the State Self Insurance Fund (SSIF) at 785-296-2364 to seek authorization prior to seeking any medical treatment. Once authorization from SSIF is received, the injured employee can contact the Business Health Center at Lawrence Memorial Hospital at 785-505-3114 to schedule an appointment. Employees are not required to seek medical treatment following the report of an injury or illness. The injured employee should understand that without the prior authorization from SSIF to seek treatment if the injury is determined to not be compensable by worker's compensation, the employee may be responsible for associated out-of-pocket expenses.

The employee will need to determine at the time of the injury, based on the severity of the injury, if they should go to the emergency room or schedule an appointment, as detailed above, with the Business Health Center at Lawrence Memorial Hospital, or determine that medical treatment is not necessary. Regardless of whether an employee seeks medical treatment, the employee must report the injury to their supervisor. If the nature of the employee's injury is serious or life-threatening, or if the accident occurs after hours, and the employee determines the medical treatment is necessary, the employee should proceed directly to the Lawrence Memorial Hospital Emergency Room, or the emergency room nearest them, and notify them that the injury was work-related.

Please keep in mind that if the injury is not deemed to be work-related, the employee may be responsible for any costs not covered by the employee's health insurance plan for the emergency room visit. Additionally, injuries that did not result from or occur in the course of employment activities may not be covered by workers’ compensation. The injured employee must provide the supervisor with any medical information, related to their work injury, provided by their healthcare provider. Please provide the employee with the Injured Worker’s First Fill Prescription Form available under "Workers Compensation Forms" on the Kansas Adjutant General website. They will need this if they seek treatment and are given a prescription. This form is given to the pharmacy the first time the prescription is filled so that they have the correct billing information. Without this form, the pharmacy may ask the employee to personally pay for the medication and the employee will have to then seek reimbursement.

Contact the EHS Safety Specialist at 785-864-4089 or with accident reporting concerns or questions.

Bloodborne Pathogens

In case of a bloodborne pathogen clean-up, please fill out the Bloodborne Pathogen Incident Form and submit it to the EHS Safety Specialist.