Report an illness or injury
The following forms may be used to report an illness or injury for workers’ compensation.
- Accident Report Form
- Accident Report Form (DocuSign Version)
- Physician Selection Form (Word version)
- Physician Selection Form (DocuSign version)
Use the checklists below for help with the workers' compensation process. For questions regarding the process, contact the VCU Human Resources Workers’ Compensation office at firstname.lastname@example.org or (804) 828-1533.
Initiating a claim
- Report injury/illness to supervisor immediately.
- Seek immediate medical treatment, if an emergency.
- Complete Accident Report Form and give to supervisor to complete as soon as possible
- Complete Physician Selection Form (Word version or DocuSign version) and seek medical treatment from selected panel physician – not your primary care physician (PCP). If you choose Concentra Telemed as your provider, see Employee Instructions for Concentra Telemed.
- Forward completed forms to VCU Employee Health Services within 24 hours of accident.
- Follow department call-in procedures.
- Keep your supervisor informed of absences, work restrictions, or job modifications.
- Follow-up with panel physician as needed.
- VSDP participants: contact VCU Leave Administration at 828-1712 and Reed Group (third-party administrator) at 1-888-827-3847 after 7 calendar days of disability.
While your claim is open:
- Communicate work restrictions and medical progress with VCU Workers’ Compensation Office.
- Keep follow-up appointments with panel physician.
- Accept recommended treatment by panel physician.
- Inform supervisor of absences and work restrictions.
- Review and sign WC agreement forms.
- Forward medical bills to your Benefit Coordinator at MCI for payment. Do not send medical bills to VCU HR.
- Keep records of your medical and physical therapy appointments. Request lost time payments from MCI via your Benefit Coordinator and provide VCU Workers’ Compensation Office with records of absences related to your claim.
- Complete blue benefits claim form provided by Virginia Workers’ Compensation Commission.
- Comply with work restrictions recommended by panel physician.
- Accept modified duty or transitional employment offered.
- Submit completed Request for FMLA (Family and Medical Leave Act) form to your supervisor – if your injury has resulted in a “serious health condition” or you have missed more than 3 days from work.
- Workers’ compensation claims process:
- VCU Workers’ Compensation Office, 804-828-1533 or email@example.com.
- Claim determination, medical authorizations, medical bills:
- Managed Care Innovations (MCI), 804-649-2288.
- Medical issues, work restrictions:
- Panel physician or Employee Health Services, 804.828.0584.
IMPORTANT: Injuries that result in hospitalization, amputation, loss of eyesight, or death must be reported immediately to Safety and Risk Management.
Helping an employee initiate a claim
- Report unsafe work conditions or safety hazards to the Safety and Risk Management.
- Inform your employee to complete the VCU Accident Report and Physician Selection Forms immediately.
- Complete in detail the supervisor's section of the Accident Report Form.
- Forward both completed forms to VCU Employee Health Services within 24 hours of accident.
Investigating the accident
- Investigate the accident promptly.
- Contact Safety and Risk Management to assist in follow-up prevention efforts.
- Determine ways to prevent future accidents.
- Counsel employee on proper safety standards.
While the claim is open
- Communicate with employee on his/her progress and work modifications.
- Communicate with Workers' Compensation Office concerning employee's progress.
- Provide employee with Request for FMLA (Family Medical Leave Act) form to complete if injury or illness resulted in a "serious health condition" or he/she has missed more than 3 days from work.
- Ensure that employee follows work restrictions recommended by panel physician.
- Seek modified or transitional duty assignments if needed by employee.
Workers’ compensation claims management:
VCU Workers’ Compensation Office, 804.828.1533 or firstname.lastname@example.org.
Claim determination, medical authorizations, billing:
Managed Care Innovations (MCI), 804.649.2288.
Medical issues, work restrictions:
Panel physician or Employee Health Services, 804.828.0584.
Department timekeeper or VCU Human Resources Leave Administration, 804.828.1712.