Workers' Compensation Forms

Workers' Comp. Report  (System & Missouri S&T Campus) - To be completed for all employees injured on the job.

• Modified Duty / Accommodated Duty Statement (PDF)
• Modified Duty / Accommodated Duty Statement (Word)

• Workers' Compensation Referral for Medical Care - Physician (PDF)
• Workers' Compensation Referral for Medical Care - Physician (Word)

• Workers' Compensation Referral for Medical Care - Therapist (PDF)
• Workers' Compensation Referral for Medical Care - Therapist (Word)

• Report of Injury Questionnaire (PDF)

• Mileage Reimbursement (Word)

 Accident Investigation Report - This form is to be completed by the appropriate supervisor for all workplace accidents where medical treatment is provided to the University employee.

• Accident Investigation Report (Word)