PLEASE NOTE : This on-the-job injury form is for Physical Plant employees ONLY. Non Physical Plant employees click here.

"Any employee who is injured on the job or develops health problems that are work related must immediately report them to their supervisor. Prompt and accurate reporting of all accidents to the supervisor is necessary to insure proper processing of claims."
(Staff Handbook, p. 10.2)

1. If you are injured on the job or develop a health problem that is work-related, you must report this information to your immediate supervisor, regardless of how insignificant the injury or health problem may seem to you at the time.
2. If the injury or health problem is deemed severe enough to require the attention of a physician, you will be sent to Student Health Services. If you prefer, you may see your own physician.
3. Your supervisor will complete the Departmental Accident Investigation report and forward it to your Superintendent for his review. The Superintendent will, in turn, forward the original to the Administrative Office with a copy to the Safety Coordinator. The Administrative Office will complete the Employee's First Report of Injury form and forward that form to the Employee Benefits Office (if you are seen at the Student Health Center, that office will complete the Employee's First Report of Injury form).
4. While at Student Health Services or your own physician's office, you need to obtain medical certification (a doctor's statement) indicating whether or not you are able to return to work. If you are able to return to work, you are to return to work, submit the medical certification to your immediate supervisor, and note the time you were off work obtaining medical attention on your Daily Time Card (white card). Your supervisor will note this time off on your clock card. If you are unable to return to work, you should have your physician send this medical certification to the Administrative Office, Department of Physical Plant, University of Louisville, Louisville, KY 40292. This certification must indicate the length of the anticipated inability to work.
5. When you return to work, you must present medical certification (a doctor's statement) stating that you are able to return to work. The Administrative office will complete a Return to Work form and forward it to the Employee Benefits Office.
6. Failure to promptly and accurately report an on-the-job injury or work-related health problem may result in over or under payment of benefits and possible disciplinary action as appropriate.