Worker’s Compensation

Injury Report Form

Attention, All Employees

Any employee who is made aware of, witnesses, or experiences a work-related injury or illness is responsible for reporting the incident to the Human Resources Office in a timely manner:

  1. Always assess the severity of the situation. Call 911 for emergencies, and seek first aid assistance for non-emergencies by contacting the Security Office at 281.425.6888. No matter how minor the incident, always report the incident to the Human Resources Department.
  2. To report an incident to Human Resources, submit a First Report of Injury (FROI) form within 24 hours of the incident. This form can be completed by the injured employee, the employee’s supervisor, or an employee witnessing the incident. Worker’s compensation resources can be accessed at lee.edu/hr/workers-compensation/.
  3. If medical attention is needed, an employee can visit an emergency room for initial treatment. Employees are required to see a provider in the Workers’ Compensation Alliance for follow-up treatment. Injured employees need to follow these steps when seeking medical treatment for an injury:
    1. Find a provider at pswca.org. Employees can also use the Wellness Works service 888.977.3319 for help finding a provider.
    2. Print and complete the Optum RX First Fill Card, in case medication is needed after the initial doctor/ER visit. Please note this is a one-time use card.
    3. Print and keep the Notice of Alliance Requirements.
    4. Complete and return the Acknowledgement of Alliance Requirements.
  • You must receive treatment from a Workers’ Compensation Alliance Medical Provider. If you do not, you may be responsible for all medical charges.

Injured Employee Notification

  • After the FROI is submitted, the employee will be contacted by the Human Resources Office to ensure that all documents listed below have been received by the employee.
    • Notice of Injured Employee Rights and Responsibilities
    • Notice of Alliance Requirements
    • Acknowledgment of Alliance Requirements
    • Acknowledgment of Leave Election Form
    • Verification of Employment Form
    • Copy of First Report of Injury (FROI)
    • Leave Election Form
    • Ombudsman Notification
  • Employees will be contacted by Texas Association of School Boards (TASB) and/or The Division of Worker’s Compensation; please comply with all requests regarding the incident.