Workers' Compensation Information

Workers' Compensation Employee Responsibilities

• You are required to report all accidents and injuries to your supervisor immediately. If your supervisor is not available, contact the Workers' Compensation Administrator ("WCA"), Benefits Specialist, at (910) 672-1451 or Human Resources Consultant, Benefits, (910) 672-1825.
• If medically necessary, you will be taken, or sent, to the medical network provider listed below after obtaining a medical authorization form from the WCA.
  • Concentra Urgent Care 1702 Owen Drive Drive Fayeteville 28304
  • Cape Fear Valley Medical Center 1638 Owen Drive Fayetteville NC 28304
• If possible, you will be given a medical authorization form to give to the medical provider to ensure that the bill for the treatment will go to CCMSI, the workers' compensation third party administrator, for payment.
• As soon as possible, you are required to complete the Employee Statement and Leave Option Form. The completed form must be given to your supervisor, or the WCA, as soon as possible after the accident or report of illness.
• If you are contacted by the CCMSI Adjuster in the claim investigation or administration process, you must provide all required information in order to expedite claim processing.
• Any absences from work related to the injury must be authorized with a statement from the treating physician. You must provide any such documentation given to you by the physician to the WCA as soon as possible.
• You are required to provide a doctor's note to the WCA stating any medical restrictions placed on you as a result of the injury.
• You must adhere to any transitional duty(s) assigned to you as part of the FSU Return to Work Program.

Worker's Compensation Supervisor Checklist

• Immediately notify The University's workers compensation administrator ("WCA") of any possible "work-related" incident, injury, or condition(s).
• In case of an emergency, or "after hours" incidents, notify The University's campus police department at (910) 672-1911, or (910) 672-1341
• Obtain a "treatment authorization form", and ensure that the employee goes to the authorized medical provider. In the event of an emergency, send the employee to the nearest medical facility. A list of authorized facilities can be found in the "Workers Compensation" section of the Human Resources webpage.
• Complete the "Supervisor Incident Investigation Report" within 24 hours, and submit it to The University's WCA.
• Provide employee with the "Employee Statement and Leave Form", and ensure that it gets completed and submitted to The University's WCA within 24 hours. *Exceptions might be made in cases of emergencies, incidents occurring during the weekendsor, "after hours", and/or when the employee remains out of work due to the incident, injury, or condition.
• Partner with the Environmental Health & Safety Office to investigate the incident.
• Immediately notify The University's WCA of any changes in the employee's medical status, or any absences due to the incident, injury, or condition.
• If necessary, identify modified duty and collaborate with The University's WCA to provide a reasonable accommodation.
• Maintain periodic contact with employee, and with The University's WCA for an effective and efficient management of the case.
• CONTACTS: 
  • (910) 672-1451, Benefits Specialist/Workers Compensation Administrator
  • (910) 672-1825, Human Resources Consultant, Benefits 
  • (910) 672-1431, Environmental Health & Safety Professional

Employee Forms

• Workers Compensation Employee Responsiblities
• Workers' Compensation Employee Statement of Injury Form
• Workers' Compensation Employee Leave Options Form
• Witness Statement Form
• Employee Release of Information- Medical and Claim Records
• Employee Release of Information- Personnel Records
• Workers' Compensation Refusal of Treatment

Supervisor Forms

WC Supervisor's Injury Data Collection Form

WC Supervisor's Checklist 

Resources

• NC State Government Workers Compensation Employee Handbook
• NC State Government Workers Compensation Supervisor Handbook
• Authorized Urgent Care Centers
• NC Industrial Commission
• NC Office of State Human Resources' Workers' Compensation Program
• Return to Work Guidelines