All three forms below are to be completed at the time of injury. Forms should be emailed to Nicole Holstein (holsteinn@wws.k12.in.us).

1. First Report of Injury (State Form 34401)

Responsibility : Building nurse or supervising administrator / administrative staff + employee

Time Frame: Immediately following incident

2. Medical Information Release

Responsibility : Completed by employee

Time Frame: Immediately following incident

3. Supervisor Incident Investigation Report

Responsibility : Supervising administrator

Time Frame: Immediately following incident

Employees requiring additional care should be provided with completed copies of above mentioned forms and be directed to:

WorkMed Occupational Health

865 Westfield Rd. Suite D

Noblesville, IN 46062

317-776-3851

Map / Instructions for Employees

Remind employees that receiving care for a workers’ comp injury from an unauthorized provider may result in the employee being held responsible for charges.

Once a claim is filed, an assigned adjuster from IPEP (our workers comp insurer) will reach out directly to the employee to assist them with the process and coordinate care as necessary.