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 (218-726-7000) and UMD Facilities Management (218-726-8262). 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

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

• 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 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 a minor injury or illness.
• Cathy Rackliffe faxes the First Report of Injury form, Employee Incident Report, and Supervisor Incident Investigation Report to Sedgwick Claims Management Services, Inc., in the Twin Cities.
• Cathy Rackliffe provides a copy of the Employee Incident Report and Supervisor Incident Investigation Report to the UMD Environmental Health and Safety Office (EHSO), except in cases of incidents filed by Facilities Management, since Facilities Management provides EHSO with a copy of the Employee and Supervisor reports directly.

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, SLOH or UMD HS, the injured employee should direct the medical provider to complete the Work Status Report and fax it to Cathy Rackliffe at 218-726-7505.

  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

  St. Luke's Hospital
  218-249-5555
  915 East First Street
  Duluth MN 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

  Coleraine employees only:

  Grand Itasca Clinic and Hospital
  1601 Golf Course Road
  Grand Rapids, Minnesota 55744

  218-326-5000 (Clinic)
  218-326-7344 (Clinic Appointments)

  Clinic hours:
  Monday through Thursday - 7:45a.m.-6:00 p.m.
  Friday -- 7:45 a.m.-4:30 p.m.
  Saturday -- 8:00 a.m.-12:00 noon

  218-326-3401(Hospital)
  Hospital Hours: 24-hours a day

  Meridian Medical Clinic
  1542 Golf Course Road
  Grand Rapids, Minnesota 55744
  218-999-7000
  Monday through Friday from 8:00 a.m. to 4:30 p.m.
  
  Meridian Urgent Care Clinic
  1542 Golf Course Road
  Grand Rapids, Minnesota 55744
  218-999-7000
  Monday and Thursday from 4:30 p.m. to 8:00 p.m.
  Saturday from 9:00 a.m. to 1:00 p.m.

• Cathy Rackliffe faxes the Work Status Report to Sedgwick.
• 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 a copy of Frequently Asked Questions.

  INFORMATION AND LINKS

  Policy: Slips, Trips, and Falls
  Work Comp Time Loss Report - WORD / PDF
  Parking Reimbursement Form
  Frequently Asked Questions - 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 Sedgwick and EHSO.

FOR QUESTIONS, 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