Occupational Injury/Illness Form

Requirement for all campuses

This 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.

• Download and complete of Occupational Injury/Illness form (Word) which includes the Authorization for Medical Records.
• Fax the completed form to IU Workers' Compensation at 812-855-2720 or email to .