Personal Job Injury Checklist
1. You have the right to receive benefits under Workers' 4. You have the right to Confidentiality.
Compensation.
5. You have the responsibility to tell your employer about
2. You have the right to receive the medical care reasonable your injury or illness within 24 Hours or in some cases 30
and necessary to treat your work-related injury or illness for Days from the date you knew your illness might be work
the rest of your life. related.
3. You have the right to the initial choice of doctor. 6. You have the responsibility to tell the doctor you were
injured and if you believe it may be work-related.
You have the right to hire an attorney to help you get benefits or to help you resolve disputes. For a FREE Confidential Consultation,
Call Jonap & Associates, P.C. Today at: (800) 741 – 7500.
Immediate
Actions Item
Action
____ 1. Obtain a copy from your employer, a Workers’ Compensation
Information and Privacy Statement form and ask them to review and
sign the statement.
____ 2. Complete Employee Statement regarding injury/illness/incident form
with instructions to complete the statement as soon as possible but no later
than 24 hours. Completed form should be returned to supervisor who will
forward to WC Coordinator.
____ 3. Complete Incident/Injury/Illness Data Form (IDF, this form replaces the
First Report of Injury or FRI) with employee and submit to WC Coordinator
as soon as possible but no later than 24 hours.
____ 4. Complete Agency Claims Investigation and submit to WC Coordinator as
soon as possible but no later than 24 hours.
____ 5. Complete Leave Supplement Form and submit to WC Coordinator for
review, select an option, and sign the statement (complete even if you have
not missed work at this time to document your intention if you should
begin to miss work). Submit the completed form to the WC Coordinator as
soon as possible but no later than 24 hours.
____ 6. Obtain your Employer’s Workers’ Compensation Employee Information
Packet. Review the documents with the WC Coordinator to ensure a clear
understanding of the process. The Workers’ Comp Employee Information
Packet may include the following documents:
Employee Information Packet introduction
Notice of Enrollment in a Certified Managed Care Plan
Care Plan Instruction Brochure
ID Card
RX Pharmacy Benefit
Report of Work Ability Form
Jonap & Associates, P.C.
ATTORNEYS AT LAW
(800) 741 – 7500
Office: (404) 320 – 6000 • P.O. Box 49466 Atlanta, GA 30359 • FAX: (404) 633 – 3300
Handout: Personal Injury Checklist