Workers' Compensation

The workers’ compensation program for State of Nebraska employees is administered by the Department of Administrative Services, Risk Management Division.

When an injury occurs, it should be reported immediately to the employee’s supervisor or Agency HR. The injured employee must complete the following forms and turn them in to Agency HR:

• Employee Incident Report;
• Authorization for Release of Information (HIPAA Compliant); and
• Employee’s Choice or Change of Doctor Form (Form 50).

Supervisors shall complete and submit to agency human resources representative:

• Supervisor Investigation Report and;
• Witness Form.

Medical Treatment Needed:

Agency HR should provide the injured employee with the following forms and information:

• 7 Day Wait Period Acknowledgment Form;
• Request to Supplement Workers’ Compensation Benefits Form;
• Report of Work Ability;
• myMatrixx First Fill Form (Replaces First Script Pharmacy Card);
• Mileage Reimbursement Form;
• Pamphlet on GBGO App.

Medical Treatment NOT Needed:

Agency HR should provide the injured employee with the following forms and information:

• 7 Day Wait Period Acknowledgment Form;
• Request to Supplement Workers’ Compensation Benefits Form;
• Pamphlet on GBGO App.

After the claim has been filed, Agency HR should complete and submit the following forms to the assigned Resolution Manager on the newly filed workers’ compensation claim:

• 26 Week Wage Statement (Note: A 52 Week Wage Statement is required for Part-Time or Seasonal Employees)
• Payroll Benefits Analysis (Biweekly or Monthly)
• Completed Employee Incident Form (From "Initial Report")
• Completed Supervisor Investigation Report (From "Initial Report")
• Completed Witness Statement(s) (From "Initial Report")

ReliaCard: A reloadable prepaid debit card for government agencies to deliver timely workers' compensation payments.