Department of Human Resources

WORKERS' COMPENSATION

Step 1: Report incident

• For Slips, Trips, and Falls incidents (University employees), must be reported IMMEDIATELY to UMD Campus Police (726-7000) and UMD Facilities Management (726-8262). This can be done by the person who has fallen, if s/he is able, or by someone in the area of the fall, or an employee's department. Proceed to Step 2.
  
• For any other work-related injury/incident, proceed to Step 2.

Step 2: Complete Employee Incident Report (WORD / PDF)

• Employee completes, signs, and dates the Employee Incident Report.
• Employee gives the signed Employee Incident Report to his/her supervisor.
• Supervisor completes, with the help of the departmental payroll coordinator, if necessary, the employment questionnaire portion of the Employee Incident Report.
• Supervisor signs and dates the Employee Incident Report.
• Supervisor promptly forwards the original Employee Incident Report to:

  Cathy Rackliffe
  UMD Workers' Compensation Coordinator
  269 Darland Administration Building
  1049 University Drive
  Duluth MN 55812-3011

  cracklif@d.umn.edu
  Tel. 218-726-6827
  FAX: 218-726-7505

• A copy of the Employee Incident Report should be retained by the employee and the supervisor.

Step 3: Supervisor completes Supervisor Incident Investigation Report (WORD / PDF)

• Supervisor completes the Supervisor Incident Investigation Report.
• Supervisor signs and dates the Supervisor Incident Investigation Report.
• Supervisor forwards the original Supervisor Incident Investigation Report to Cathy Rackliffe.
• A copy of the Supervisor Incident Investigation Report should be retained by the employee and the supervisor.

Step 4: Department of Human Resources completes First Report of Injury

• Cathy Rackliffe completes the First Report of Injury form for serious illnesses and serious injuries, and when an injured employee has sought medical attention for even a minor injury or illness.
• Cathy Rackliffe FAXes the First Report of Injury form, Employee Incident Report, and Supervisor Incident Investigation Report to Cindy Weingart of Sedgwick Claims Management Services, Inc. (Twin Cities) and Terry Teachout, Director of Workers' Compensation, University of Minnesota.
• Cathy Rackliffe provides Norbert Norman, UMD Office of Environmental Health and Safety, with a copy of the Employee Incident Report and Supervisor Incident Investigation Report, except in cases of incidents filed by Facilities Management. As a matter of practice, Facilities Management provides Norbert Norman with a copy of the Employee and Supervisor reports.

Step 5: Physician completes Work Status Report (WORD / PDF)

• Injured employee seeks medical attention. This step may come before Step 1 in cases of serious injury/illness.
• Injured employee brings to the medical appointment a Work Status Report for completion by the treating physician. If seen by a physician at Duluth Clinic Occupational Medicine (DCOM), St. Luke's Occupational Health (SLOH), or UMD Health Services (UMD HS), employee need not provide a Work Status Report, since those medical providers have their own reports.
• If other than DCOM or UMD HS, the injured employee should direct the medical provider to complete the Work Status Report and FAX it to Cathy Rackliffe at 726-7505.

  For appointments at DCOM, SLOH, or HS, call:

  St. Luke's Occupational Health
  218-249-6822
  4702 Grand Avenue
  Duluth, Minnesota 55807
  Monday through Friday
  8:00 a.m. - 4:30 p.m.

  Duluth Clinic Occupational Medicine
  218-786-3392
  400 East Third Street
  Duluth, Minnesota 55805
  Monday through Friday
  8:00 a.m. - 4:30 p.m.

  Minor injuries may be referred to:

  UMD Health Services
  218-726-8155
  615 Niagara Court
  Duluth Minnesota 55812
  Monday through Friday
  8:00 a.m. - 4:30 p.m.
  Summer hours: 9:00 a.m. - 3:00 p.m.

  After hours, on weekends or holidays:

  St. Mary's Medical Center/Emergency Care and Trauma Center
  218-786-4000
  407 East Third Street
  Duluth, Minnesota 55805
  Sunday through Saturday
  24-hours a day

  Serious burn injuries should be referred to:

  Miller-Dwan Medical Center, Burn Unit
  Tel. 218-727-8762
  TTY Hearing Impaired: 218-720-1950
  502 East Second Street
  Duluth, Minnesota 55805

  NRRI / Coleraine employees only:

  East Grand Rapids Clinic
  218-326-5000
  111 S.E. Third Street
  Grand Rapids, Minnesota 55744
  Monday through Thursday -- 8:00 a.m. - 6:00 p.m.
  Friday -- 8:00 a.m. - 4:30 p.m.
  Saturday -- 8:00 a.m. - noon

  Grand Rapids Hospital
  218-326-5000
  111 S.E. Third Street
  Grand Rapids, Minnesota 55744
  Sunday through Saturday
  24-hours a day

• Cathy Rackliffe FAXes the Work Status Report to Cindy Weingart and Terry Teachout.
• Cathy Rackliffe provides the employee's department with a redacted copy of the Work Status Report or calls or emails employee's department with work status information.

• Supervisor or his/her designate provides employee with webpages for UMD HR Workers' Compensation information, policies, and forms.
• If employee does not have access to a computer, Supervisor or his/her designate provides employee with Workers' Compensation Informational Brochure and Frequently Asked Questions by Employee, along with policies on Reporting Work Related Injuries and Reporting Workers' Compensation Related Injuries.

  INFORMATION AND LINKS

  Policy: Reporting Work Related Injuries - WORD / PDF
  Policy: Reporting Workers' Compensation Related Injuries - WORD / PDF
  Policy: Slips, Trips, and Falls
  Work Comp Time Loss Report - WORD / PDF
  Parking Reimbursement Form
  Workers' Compensation Informational Brochure - WORD / PDF
  Frequently Asked Questions by Employees - WORD / PDF
  Frequently Asked Questions by Supervisor - WORD / PDF

Step 7: Supervisor/Department Completes Workers' Compensation Time Loss Report

• Supervisor/Department completes the Time Loss Report for days employee missed from work due to a work-related injury. Do not report the first three days from the date of the incident unless the employee misses ten or more days. If that is the case, then all time loss days retroactive to the first day of the injury are reported.
• Supervisor/Department signs and dates the Time Loss Report and forwards the original to Cathy Rackliffe.
• Cathy Rackliffe FAXes a copy of the Time Loss Report to Cindy Weingart (or assigned claim representative) and Terry Teachout. She provides a copy to Norbert Norman.

FOR QUESTIONS, PLEASE CONTACT:

Cathy Rackliffe
UMD Workers' Compensation Coordinator
269 Darland Administration Building
1049 University Drive
Duluth, Minnesota 55812-3011

Telephone: 218-726-6827
FAX: 218-726-7505
Email: cracklif@d.umn.edu