Workers' Compensation Forms

CorVel Approved Provider List
Listing of all CorVel authorized Urgent Care and Emergency Room facilities in North Carolina.  This list should be referred to if the employee is out of the area when injured.

Employee Incident Report Form
The employee incident report is the employee’s recollection of the details of the injury.  The report should be completed by the employee, and signed and dated as soon as possible after the injury occurs.

Employee Use of Leave Options Form
Employees who miss time from work, should use this form to document their waiting period leave selection as well as select rather or not they want to utilize supplemental worker’s compensation payment after the seven day wait period.

Supervisor’s Incident Investigation Report
The supervisor’s incident report is the supervisor’s recollection of the details surrounding the employee’s injury on the job. The supervisor’s report will list any details that may correct the problem or to increase awareness in the department and the supervisor and employee.

Worker’s Compensation Refusal of Treatment Form
This form should be completed by injured workers who refuse treatment post injury.

NC Witness Statement Form
This form can be used by any witnesses to injuries that occur on campus.

Worker’s Compensation Employee Handbook
Handbook created by the Office of State Personnel to assist employees with information regarding the Worker’s Compensation process and associated policies and procedures.

Non-Occupational Statement Form
This form should be used for all injuries not classified as work related.  Injuries for visitors and students can be documented using this form.

Worker’s Compensation Fraud or Abuse Allegations Report Form
Please complete this form if you have witnessed a case of fraud or abuse by a Worker’s Compensation claimant.

Form 17 Notice to Injured Workers and Employers
NC Industrial Commission Worker’s Compensation Notice to Injured Workers and Employers

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