Occupational Injury/Illness Form

This form is required for all campuses

The occupational injury/illness form contains employee health information and must be used in a manner that protects the confidentiality of the employee to the extent possible while the information is being used for occupational safety and health purposes.

This form includes iincludes the Authorization for Medical Records.

Download the Occupational Injury/Illness form (Word) 

Complete the form, then submit it to IU Workers’ Compensation by fax or email:

Fax: 812-855-2720

Email: workcomp@iu.edu