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Treatment Authorization Form




For any incident resulting in a serious or life threatening injury to an employee, call 911 for emergency medical care.

For incidents that are not serious or life threatening, the injured employee must contact their supervisor and advise them of the injury. If the injured employee is unable to contact his/her supervisor, a co-worker may do so for them.


Any injury or Illness arising out of the course of employment is to be reported to the injured employees supervisor immediately.


If the injured employee needs medical attention, the supervisor, or designee in his/her absence, shall see that the injured employee receives the required medical treatment.

The supervisor should ensure the employee has transportation to the designated medical facility (Preference should be given to use a university vehicle).

It is necessary to notify the care-givers that it is a work-related injury and to bill directly to the Workers Compensation Section of Human Resources. A "Treatment Authorization Form" (see "Forms" section on right side of this page) should accompany the employee to the designated medical facility at this time, if possible.


Immediately after ensuring medical attention, the supervisor should initiate an accident investigation to focus on the cause(s) of the accident and subsequent corrective actions. Assistance with investigations shall be available from EHS if necessary.


  • After completing the investigation, the supervisor shall complete and submit the "Online Injury/Illness Log" (see "Supervisor Only Online Injury/Illness Log" section under Accident Reporting on left side of this page).

  • The Online Injury/Illness Log will prompt the supervisor if individual has sought off site medical attention. If so, the system will direct the Supervisor to the required Workers Compensation forms required by the State of Illinois Division of Workers Compensation. These forms are to be completed and submitted via campus mail to Human Resources / Workers Compensation Section at ISU.

  • If there is a witness to the accident, he/she should complete a Witness form supplied by the Supervisor. If the witness refuses to complete this form, the supervisor should record the witness name and write "Refused" across the form, initial and date it, and forward it to the Human Resources.

Workers' Compensation

The initial claims process begins with the injured or ill employee promptly informing his/her supervisor of the injury or illness. Upon notification, the supervisor will direct the employee to contact the TriStar/CMS Early Intervention Program via the toll-free injury reporting hotline (1-855-495-1554) to initiate a claim.

The supervisor will then promptly (within 24 hours of learning of the incident) complete the Online Injury/Illness Log located on the Environmental Health and Safety home page. The Injury/Illness Log should only be accessed by the supervisor of the injured or ill employee. As part of the Injury/Illness Log process, a series of questions will direct the supervisor to whether or not additional Tri-Star forms need to be completed. These forms may include:

  1. Workers' Compensation Employee's Notice of Injury

  2. Supervisor's Report of Injury or Illness

  3. Workers' Compensation Witness Report

  4. Authorization to Disclose Medical Information


All bills regarding the work-related injury should be sent directly to the Human Resources Office for processing. If the employee is personally billed or was required to pay at time of service by the medical facility/pharmacy, he/she shall submit their bills, receipts and completed forms to the ISU Workers Compensation Administrator to process for payment in a timely manner.

2017-09-13T14:58:27.13-05:00 2017