Argus II Building
400 South Fourth Street
Ann Arbor, MI 48103-4816
Phone: (734) 615-0643
Toll-free: (877) 869-5266
Fax: (734) 936-1913
E-mail: Work.Connections@umich.edu
Website: workconnections.umich.edu
University of Michigan Work Connections Illness and Injury Assistance

Illness or Injury Report Form

State law requires the employer to provide medical care at a designated medical facility. Within the first 10 days the employee is required to treat at the employer's dedicated medical facility. If you need the name of a designated medical facility, call Work Connections. For serious incidents, please call Work Connections immediately. Complete and submit this form within 24 hours of notification of injury.

Faculty or Staff Member Information. Complete this section for ALL illnesses or injuries.
Employment
Was this person out of work due to the illness or injury?
If yes, give dates:
Has this person returned to work?
Were there restrictions on the work he or she could do?
Have those restrictions been accomodated?
Scheduled Workdays:
Shift:
Injury/Incident Information. Complete this section only for work-related illness or injury.
Did incident involve a motor vehicle?
Was treatment declined?