In the event of a medical emergency, call 911.
In the event of a work-related injury/incident/illness, please call:
Carol Brewer, Director of Safety and Security at (320) 308-6158 (email@example.com) or Julie Simonson, Workers’ Compensation coordinator, at (320) 308-5464 or firstname.lastname@example.org.
Work related injuries may require regulatory reporting. Notify your agency’s Workers’ Compensation Coordinator (WC Coordinator) as soon as possible of any serious, life threatening, or fatal injuries or events that result in multiple hospitalizations. Not reporting within the required time periods may result in monetary penalties.
Workers' Compensation Forms
The following forms are to be completed and submitted to your agency Workers' Compensation Coordinator as soon as possible but no later than 24 hours after the incident.
Information and Privacy Statement Form
This form should be given to the injured worker prior to collection of any data needed to fill out and file a first report of injury. This form is used to ensure compliance with the Minnesota Government Data Practices Act.
Injury, Illness, Incident Data Form (replaces First Report of Injury)
This form is to be completed by the Safety & Health Officer or the injured employee’s supervisor.
Employee Statement Regarding injury/illness/incident
This form is to be completed by individuals reporting an injury, illness or incident. Supervisors should have the person reporting the incident compete the form as soon as possible after the incident.
Please contact Julie Simonson in Human Resources with questions. She may be reached at (320) 308-5464 or email@example.com.