Workers’ Compensation Process for DHHS Employees

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.   PDF 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 PDF Employee Injury Incident Report Packet and send to 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 HR
·         Supervisor Investigation Report – Return to HR
·         Witness Form- Supervisor should have all individuals that witnessed the injury complete
          this form - Return to HR
·         7 Day Wait Period Acknowledgment Form – Return to HR
·         Request to Supplement Workers Compensation Benefits Form- Return to HR
·         Report of Work Ability- Must be completed at each medical appointment and returned
          to the Workers’ Compensation Coordinator no later than 24 hours after the
          appointment.PDF Report of Work Ability
·         First Script Pharmacy Form – You will take this with you when filling a prescription for
          your injury.
·         Mileage Reimbursement Form
·         Pamphlet on GBGO App.


The Workers' Compensation Process:

The PDF 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


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