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RCTC Reasonable Accommodation Procedure and Forms

Reasonable Accommodation Procedure

Reasonable Accommodation Request Form

Workers Compensation Information and Forms

DOER Workers Compensation Home Page

Workers Compensation Information and Privacy Statement

 

• This form should be given to the injured worker PRIOR to collection of data needed to fill out and file an FRI. This form is used to ensure compliance with the Minnesota Government Data Practices Act.

First Report of Injury Form

 

• This form is used to collect the necessary information regarding an injury or illness that may be work related. The information collected through this form is used by the agency to facilitate the entry of a claim into SEMA4 for workers' compensation coverage to the State Workers' Compensation Program. The form also acts as the employer's incident investigation form (OSHA301) and meets the requirements of the OSHA record keeping standard. Please check with your agency safety administrator and/or human resource office to determine whether your office is using this form or an equivalent form designed by your agency.

Workers Compensation Leave Supplement Form

 

• This form (or agency equivalent) is used by employees to document their decision to supplement their workers' compensation payment with accrued but unused sick, vacation, or compensatory time.

Agency Claims Investigation Form

 

• This form (or agency equivalent) is to be completed by the employee's immediate supervisor or agency designee and supplements the First Report of Injury (FRI).

26-Week Wage Information Form

 

• This form is only to be submitted by those organizations who do not have access to the SEMA4 system and who require the assistance of DOER to provide workers' compensation coverage. This form is used to document employee's earnings when earnings are irregular, difficult to determine, or consist of overtime, differential or other special pay in at least one-half of the work weeks in the 26 weeks preceding the date of injury. If the employee's work status has changed during the 26-week period (e.g., full-time to part-time, part-time to full-time, promotion, demotion or is a new hire) provide wages only since the date of the most recent work status change and note the type of change. For organizations that can file the First Report of Injury through the SEMA4 system, a 26-week earnings report will be generated automatically.

Report of Workability Form

 

• This form should be obtained by agencies when employees return to the job following a work-related injury. Most health care providers have their own Report of Work Ability form. If a health care vendor does not have their own form you can print this form for their use.

 

 

 

Rochester Community and Technical College
851 30th Ave SE, Rochester, MN 55904-4999
Contact Info: (507) 285-7210 or 1-800-247-1296 / TTY Relay 1-800-627-3529
RCTC is a University Center Rochester partner and a member of the MnSCU system.
© 2007 Rochester Community and Technical College, All rights reserved.
RCTC is an affirmative action, equal opportunity educator and employer.
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