PLEASE NOTE: The forms on this page must be completed only with the Adobe© Reader. Using other programs will result in lost data on the form. Some of the forms can be completed and saved to your local drive. Adobe© Reader is free from adobe.com — click on the icon to download.

 

  • Initial Medical Evaluation Authorization
    The supervisor should complete this form and send it with the employee to The Workplace for medical treatment. (If injury occurs after hours or in event of life-threatening injury, send the employee to the University Hospital Emergency Department.)
  • OJI Incident Report
    Do not use this form if you have access to Trend Tracker, the electronic incident reporting system. If you do not have access to Trend Tracker, the paper incident report form must be completed by employee and signed by the supervisor to be forwarded directly to: 
    Leticia Tatum | AB 216
    If employee is unable to complete the form, the supervisor can complete it.
  • How to Apply for OJI Benefits
    This form contains information for the employee about the OJI Program. The injured employee should read this form carefully.
  • OJI Benefits Application
    An employee applying for OJI Benefits must fill this form out completely in order to be considered.
  • Release of Information
    This form should be filled out by the employee. Any incomplete or altered forms will result in a delay of the claim process.
  • OJI Time Sheets
    The supervisor should complete this form on the eligible biweekly employee and forward in a timely manner to avoid delay in payment of lost time wages.