University of Michigan Work Connections Illness and Injury Assistance

Forms

How to complete and submit forms to Work Connections

Illness or Injury Report Form

Illness or Injury Report Form

This form should be completed by the supervisor for ALL work-related injuries or occupational illnesses. For all non-work-related disabilities, the form may be completed by the supervisor or employee.

Complete the Illness or Injury Report Form

Form Instructions
The Illness or Injury Report form can be completed and submitted entirely online.

Authorization to Release Patient Information Form

Authorization to Release Patient Information

Work Connections staff work with the treating physicians to assist in facilitating medical care for employees. This form authorizes Work Connections to obtain medical documentation and discuss an employee's medical condition and treatment with physicians.

Fill Out the Authorization to Release Patient Information Form

Form Instructions

  1. Employees should complete this form in its entirety via the button above.
  2. Print the form.
  3. Sign and date the form.
  4. Return the signed form to Work Connections via email, fax, or U.S. mail.
Mileage Reimbursement Form

Mileage Reimbursement Form

University employees requesting reimbursement for mileage associated with medical treatment for work-related injuries or illnesses should complete this form.

Complete the Mileage Reimbursement Form

Form Instructions
The Mileage Reimbursement form can be completed and submitted entirely online.

Download Work Connections forms

These forms are viewable in Adobe Acrobat Reader. Click here to download the reader from the Adobe Web site.