Purpose  Scope Policy Procedure Related Forms: Employee's Statement for Work-Related Injury Supervisor's Accident Report Employee Handout Related Links: State Government Worker's Compensation Program UNCW Environmental Health & Safety

Effective November 2004, the Employee's Statement for Work-Related Injury and the Supervisor's Accident Report are available in "PDF" format. These forms may be filled out on-line and printed for signature or print a blank form and fill out by hand or typewriter.

A. Purpose

Explains university policies and procedures concerning workers' compensation claims filed against The University of North Carolina at Wilmington and the reporting of workplace injuries and illnesses.

B. Scope

Applies to all university employees regardless of status or type of appointment. Student employees who are injured in the course of their employment are also covered by this procedure. Volunteers are not covered by this procedure.

C. Policy

General Statement 

All employees of the university are covered by the North Carolina Workers' Compensation Act, including part-time, temporary and student workers. Any employee who suffers an accidental injury arising out of and in the course of employment or who contracts an occupational disease within the meaning of the Workers' Compensation Act is entitled to medical attention at the expense of the university. If applicable, the injured employee is also entitled to disability compensation, including a weekly compensation benefit for time lost from work.

1.    Coordination with Other Agencies


       a.   North Carolina Industrial Commission

This agency establishes the rules and regulations under which the Workers' Compensation Act is administered. Determination of liability and all bills for payment as a result of the injury will be processed according to these rules and regulations. In cases where the university and the injured employee cannot agree on liability or compensation, the Commission will hold hearings.

       b.   North Carolina Department of Labor - OSHA Recordability Requirements

Workplace injuries and illnesses that may qualify under the Occupational Safety & Health Administration may or may not be qualified as Workers' Compensation. With the assistance of Human Resources and the reporting department, Environmental Health & Safety will determine the accident status for OSHA recordkeeping.

       c.   Third-Party Administrator

The State of North Carolina has contracted a third-party administrator to handle Workers' Compensation claims. The third-party administrator is responsible for determination of liability, authorization of treatment, bill processing, weekly compensation benefits, and forms filing. Contact Human Resources for the name and telephone number of the current third-party administrator and the university's adjuster.

2.    Reporting Requirements

        a.   Reporting by Injured Employee

All work-related injuries or illness must be reported immediately (or as soon as possible) to the employee's supervisor/department head by the employee or his/her representative. Delay in reporting job injuries or illness may result in the loss of benefits.

To ensure the timely payment of benefits, the employee is required to provide written notice of the accident/injury to Human Resources within five days of occurrence of the accident/injury. To fulfill this requirement, the employee should complete the "Employee Statement for Work-Related Injury." (See Procedure statement 1.)

No compensation shall be payable unless written notice is given to the university by the employee (or his/her representative) within 30 days after occurrence of the accident or death, unless reasonable excuse is made to the satisfaction of the Industrial Commission for not giving such notice and the Commission is satisfied that the employer has not been prejudiced thereby.

b.   Reporting by the Supervisor/Department Head

All work-related injuries or illnesses must be reported to the Environmental Health and Safety Department (910-962-3057) and Human Resources (910-962-3392) immediately. Additionally, any hazardous working conditions that may have contributed to the accident must be reported immediately to the Director of Environmental Health and Safety and to the employee's supervisor so that arrangements for investigation and correction can be made.

Within 24 hours of knowledge of the injury, the supervisor/department head must complete the Supervisor's Accident Report and submit the completed report to the Workers' Compensation Administrator in Human Resources and the Director of Environmental Health & Safety.

Environmental Health & Safety may require additional forms or information, including employee work schedules, assigned tasks, lost or restricted days and initial and follow-up medical visits to complete required OSHA recordkeeping. All medical information required by Environmental Health & Safety will be provided by Human Resources.

c.    Reporting to North Carolina Industrial Commission

The university is required by law to provide a written report to the North Carolina Industrial Commission within five days from knowledge of any injury that results in more than one day's absence from work or if medical expenses exceed an amount determined by the North Carolina Industrial Commission. Responsibility for reporting to the North Carolina Industrial Commission rests with the Third-Party Administrator.

d.   Reporting to the North Carolina Occupational Health and Safety Administration and OSHA Recordability  

If an accident results in the death of one or more employees and/or hospitalization of three or more employees, the supervisor/department head must immediately notify Environmental Health & Safety or if after business hours, advise University Police to contact Environmental Health & Safety immediately. Additionally, all fatal heart attacks occurring in the workplace, whether or not work-related, must be reported to Environmental Health & Safety immediately.

The Envirnomental Health & Safety OSHA Recordkeeper must determine recordability and log the injury/illness witin seven (7) days of occurrence. The supervisor/department head must report all lost and restricted work activity days resulting from the injury/illness to the Environmental Health & Safety Department.

3.    Investigation Responsibility

a.   All accidents are to be investigated immediately by the employee's supervisor/department head.

b.   Serious accidents are to be further investigated by an investigative team that should include the employee's supervisor and the Director of Environmental Health and Safety.

4.    Claims for Compensation


Responsibility for claiming compensation rests on the injured employee. The employee, through the university, must file a claim with the North Carolina Industrial Commission within two years from the date of injury or knowledge thereof. Otherwise, law bars the claim.

1.    Appropriate Medical Attention

Employees are required to seek treatment for work-related injuries from the university's approved medical providers. The supervisor should arrange appropriate medical attention as indicated below. Employees who refuse medical treatment should sign a statement acknowledging that medical treatment was offered and refused.

Life-Threatening Injury   Call University Police (4911).

Serious Injury Employee should be taken to Cape Fear Hospital Emergency Room (Telephone: 452-8112). Call University Police (4911) for emergency transportation.

Non Life-Threatening Injury Employee should be taken to MEDAC II, 1442 Military Cutoff Road, 8AM-8PM, 7 days a week (256-6088).

2.    Employee's Statement for Work-Related Injury

After the injured employee has completed the "Employee Statement," the form will be given to the employee's supervisor/department head. The supervisor will investigate the accident and verify the employee's statement or submit an attached statement of facts developed during the investigation. The supervisor/department head will forward the completed form to the Workers' Compensation Administrator in Human Resources and to the Director of Environmental Health & Safety.

3.    Supervisor's Accident Report Form

The Supervisor's Accident report form shall be prepared immediately after an employee reports a work-related injury or illness. The supervisor/department head shall specify what corrective action, if any, was taken. It is the responsibility of the supervisor/department head to see that this form is completed accurately and that the hazards identified have been controlled. The supervisor/department head should submit one copy of the Supervisor's Accident Report form to the Director of Environmental Health and Safety and another copy to the Workers'Compensation Administrator in Human Resources.

4.     Bills and Payment for Medical Expenses

  a.   Payment of all reasonable medical, surgical, hospital, nursing, sick travel, medicines, and rehabilitation services that are prescribed by the approved medical provider to effect a cure or give relief will be covered by Workers' Compensation for compensable injuries. The approved medical provider will bill the university, or the third- party administrator, directly for these expenses.

   b.  Prescriptions written by an approved medical provider may be filled at any pharmacy. Employees should contact the Workers' Compensation Administrator for reimbursement if any expenses are incurred for prescriptions.

5.   Leave Policy

a.   Transitional Work Program
Unless prohibited by the approved treating physician, employees are expected to return to work following a work-related injury. The university provides alternative work assignments in accordance with the State's Return to Work Program. Any restrictions or accommodations identified by the approved physician will be followed. Transitional work assignments may be within the employee's own unit or, if necessary, in another department or division. Sick leave may not be used in lieu of returning to work in a transitional position. Supervisors should contact the Workers' Compensation Administrator in Human Resources for assistance in providing transitional work.


  b.   Time Lost from Work on Day of Injury
The injured employee will be paid full salary the day of the injury and will not be charged leave for time lost from work on the day of the injury. However, the employee is expected to return to work after medical treatment on the day of the injury, unless the approved medical provider has prohibited return to work.


  c.  Use of Leave for Additional Medical Treatment

Employees who require additional medical visits authorized by the third-party administrator are not charged leave for reasonable time away from work for these appointments. Employees should try to schedule appointments at a time most convenient for their work unit.


  d.   Additional Time Lost From Work

If the injury results in lost time away from work due to the physician's prohibiting return to work or the university's inability to provide transitional work, the employee must go on Workers' Compensation leave.

1.   Waiting Period

Workers' Compensation leave requires a seven-day waiting period. The following options are available during the waiting period:

      (a)  Exhaust Leave to Remain in Paid Status

Employees may use accumulated vacation or sick leave during the required waiting period to remain in a paid status and then go on Workers' Compensation leave and begin drawing Workers' Compensation weekly benefits. NOTE: Compensatory time may be substituted for sick or vacation leave if applied within the time frames provided under the Hours of Work and Overtime Compensation Policy.

      (b)  Leave Without Pay

Employees may take leave without pay for the required waiting period and then begin drawing Workers' Compensation weekly benefits.

2.    Workers' Compensation Weekly Benefits

After the seven-day waiting period, the employee will be eligible to receive 2/3 of weekly average earnings, up to a maximum benefit to be determined annually. However, if the employee has accumulated vacation or sick leave, the employee may supplement Workers' Compensation according to a leave schedule available from Human Resources. If disability continues more than 21 days, the seven-day waiting period is reimbursed in the fourth week of compensation.


3.    Salary Continuation for Law Enforcement Officers

Law enforcement officers who are subject to the Criminal Justice Training and Standards Act are eligible to receive full salary compensation for up to two years if incapacity is the result of an injury by accident or occupational disease out of and in the course of their official duties.

6.   Continuation of Benefits While on Leave

a.  Medical Benefit

The university continues to pay the monthly premium for the employee. Premiums for any dependent coverage must be paid by the employee directly to the UNCW Payroll Department. The employee must pay premiums for any dependent coverage directly to the UNCW Payroll Department.

b. Vacation and Sick Leave

The employee will continue to accumulate vacation and sick leave while on Workers' Compensation leave.

c.   Longevity Pay (SPA only)

SPA employees eligible for longevity pay will receive annual longevity payments while on Workers' Compensation leave.

d.   State Retirement Service Credit

The employee will not receive retirement credit while on Workers' Compensation leave.  However, as a member of the State Retirement System, service credits may be purchased in a lump sum payment. The cost is shared by the employee and the University. If payments are not made within six months of return to service, a penalty of 1% per month shall be assessed to the total cost.

Direct any questions concerning the continuance of benefits while on Workers' Compensation leave to Human Resources.

e.   Legislative Increases

Upon return to work, the employee's salary will be computed based on the employee's last salary plus legislative increase, if any. The employee may also be eligible for a performance increase, if the increase would have been awarded had the employee been at work.