Workers' Compensation Benefits:
Worker' Compensation in Nebraska is designed to provide certain benefits to employees who sustain injury by accident or occupational disease arising out of and in the course of their employment, and who are not willfully negligent at the time of the injury. Your Rights and Obligations Under the Work Comp Law
Employee health and safety are a priority of the Department of Health and Human Services. It is important that all employees follow safety procedures and bring potential hazards to the attention of their supervisor to avoid employee accidents and injuries.
In spite of this, accidents may still occur. When they do, IMMEDIATELY:
Notify your supervisor and fill out or cooperate in filling out the Employee Injury Incident Report Packet
and send to DHHS.myHR@nebraska.gov
or fax to 402-742-2384
(Attn: Work Comp Team)before the end of your work shift. Failure to report the injury/illness immediately may result in denial of worker's compensation benefits
Included in the packet:
Employee Incident Form – complete all portions of this form - Return to HR
Authorization for Release of Information (HIPAA Compliant) –
Return to HR
Employee’s Choice or Change of Doctor Form (Form 50) - Return to
Supervisor Investigation Report – Return to HR
Witness Form- Supervisor should have all individuals that
witnessed the injury complete
this form - Return to HR
Day Wait Period Acknowledgment Form – Return to HR
to Supplement Workers Compensation Benefits Form- Return to HR
of Work Ability- Must be completed at each medical appointment and returned
to the Workers’ Compensation Coordinator no later than
24 hours after the
First Script Pharmacy Form – You will take this with you when
filling a prescription for
Mileage Reimbursement Form
Pamphlet on GBGO App.
The Workers' Compensation Process:
The Worker's Compensation Process document will explain how to submit medical bills, time sheets, and the Workability forms.
Occasionally, you may need to seek outside medical attention or miss some work. If you don’t have a regular physician and need to seek medical attention due to a work-related injury, your supervisor and/or worker’s compensation coordinator will provide you with a list of authorized providers.
The goal is to get you back to a productive work status as soon as possible, and to help maintain your well-being, your salary and benefits.
Supervisors: for more information, email Human Resources, Attn: Workers' Comp Coordinator, at DHHS.myHR@nebraska.gov.