EFFECTIVE DATE: June 14, 2019
ISSUE #: 5
PRESIDENT: Juan Sánchez Muñoz
This Policy Statement ensures University of Houston-Downtown (UHD) employees who
suffer work-related occupational injuries and illnesses receive prompt, appropriate medical
care and treatment, and compensation as allowed and provided by the Texas State Labor Code, Chapter 401, Title 5, Workers’ Compensation (Texas Workers’ Compensation Act),
SAM 01.C.03, Reporting Work Related Injuries and Illnesses, and other state and
institutional guidelines covering workers’ compensation.
2.1 Employee: Any person employed by and paid through the University of Houston-Downtown’s payroll system. It does not include independent contractors, volunteers,
except during a Governor-declared State of Emergency, members of the state military
forces, except while on active duty, persons covered by Federal worker’s
compensation, offenders, students or patients of a state agency.
2.2 Supervisor: Any employee having supervisory responsibilities, either temporary or
permanent. For the purposes of this policy statement, in most cases the supervisor
acts as the representative of the employer.
2.3 Occupational accident: A sudden, unplanned, unintentional event or occurrence that
interrupts the efficient completion of a work related activity.
2.4 Occupational illness: Any disease arising out of and in the course of employment
with the University of Houston-Downtown that causes damage or physical harm to
the physical structure of the body and such other diseases or infections as naturally
2.5 Occupational exposure: An exposure to a condition or conditions that may result in
the contraction of an occupational illness.
2.6 Occupational injury: Physical harm or damage occurring to an employee because of
an accident or an event compensable under the Texas Workers’ Compensation Act
and arising out of, or in the course of, the employee’s employment with the University
2.7 Disabling illness or injury: An illness or injury that prevents the employee from
returning to regular work or job assignment on the next scheduled workday following the date of the illness/injury.
2.8 Lost time: Any work time lost due to occupational injury or illness after the original
date of injury or first symptom of illness.
2.9 Medical care/expenses: Health care reasonably required by the nature of a
compensable injury or illness and intended to cure or relieve the effects naturally
resulting from the compensable injury/illness, resulting in reasonable expenses for
necessary treatment to cure and relieve the employee from the effects of occupational
2.10 Employer Wage Information: An online State Office of Risk Management (SORM)
form completed by the UHD Benefits staff, which is used to determine the injured
worker’s weekly wages and will be used to calculate his/her benefits.
2.11 Physician’s Release to Work: Statement from employee’s treating physician that
states the employee may return to work.
2.12 Employer’s First Report of Injury or Illness (DWC-1S): Form that must be completed
electronically by the UHD Benefits staff to SORM for any occupational injury/illness
in which an employee incurs medical expenses or loses time from work due to a work
related accident or incident.
2.13 Employee’s Wage Statement (DWC-3): Report obtained from the Payroll Department
used to determine the injured worker’s weekly wages and submitted to SORM by the
UHD Benefits staff.
2.14 Supplemental Report of Injury Form (DWC-6): Report submitted electronically by
the UHD Benefits staff each time any of the following events occur:
a. The employee is unable to return to work due to a work-related injury;
b. The injured employee returns to work in any capacity;
c. The injured employee earns less than the pre-injury wages because of the
d. The injured employee is terminated, resigns, or dies.
2.15 Texas Workers’ Compensation Work Status Report/Physician’s Release to Work(DWC-73): Form completed by the employee’s treating physician explaining an
injured employee’s medical restrictions or ability to work.
2.16 Authorization for Release of Information (SORM-16): Form completed by the
employee to authorize SORM to obtain relevant medical information from providers
that will assist in the handling of the claim.
2.17 Employee’s Report of Injury (SORM-29): Form completed by the injured employee
to provide SORM with information pertaining to the circumstances surrounding the injury and what has happened since the date of injury.
2.18 Witness Statement (SORM-74): Form to be completed by anyone who witnessed or
has information to provide regarding the accident. The report should be completed as
soon as possible to assure important facts are not forgotten by the witness.
2.19 Employee’s Election Regarding Utilization of Sick Leave (SORM-80): Form that
allows an injured employee the election of using all accrued sick leave and all annual
leave, or a portion of accrued annual leave, or no annual leave or no sick or annual
leave before receiving weekly compensation benefits.
2.20 Notification of Additional Information (SORM-90): Report submitted electronically
to SORM by the UHD Benefits staff after changes in employee information occur.
2.21 Supervisor’s Report of Accident: Form that must be completed by the injured
employee’s supervisor or a person designated by the supervisor when an occupational
illness or injury occurs.
2.22 Workers’ Compensation Network Acknowledgement Form: Form to be filled out by
the employee at the time of hire. The form requires the employee to acknowledge that
they have received information on how to obtain health care services under workers’
2.23 ealth Care Network: The network contracted by SORM to assist employees in the
selection of network providers while obtaining prompt and appropriate medical
3.1 The University of Houston-Downtown (UHD) is committed to maintaining a safe
working environment free of hazardous conditions for all faculty, staff, and students.
However, when unavoidable incidents arise, it is important that employees suffering
from a work-related occupational injury or illness receive proper medical attention
and that the proper documentation is completed and forwarded to the State Office of Risk Management (SORM) so that compensation may be paid should the employee
be temporarily or permanently disabled.
3.2 When an employee is injured on the job, suffers an occupational disease, or dies as a
result of an occupational disease or job-related injury, the employee (or person acting
on the employee’s behalf), the supervisor, the UHD Environmental Health and Safety
(EHS) Office representative, and the UHD Benefits staff each have responsibilities
regarding reports and actions to be taken.
3.3 All employees requiring emergency medical treatment for a work-related
occupational injury or illness are entitled to such treatment as authorized by the Texas Workers’ Compensation Act.
3.4 To receive workers’ compensation benefits in a timely manner, the reports and actions
defined herein must be initiated within the time frame prescribed in this policy
3.5 No workers’ compensation benefits can or will be paid until the Employer’s First
Report of Injury or Illness Form (DWC-1S) is received by SORM.
3.6 The UHD Benefits staff is responsible for reviewing SORM reporting forms on an
annual basis to assure that current forms are utilized for all workers’ compensation
3.7 Texas Worker’s compensation benefits are not applicable to independent contractors,
volunteers, except during a Governor-declared State of Emergency, members of the
state military forces, except while on active duty, persons covered by Federal
worker’s compensation, offenders and students or patients of a state agency.
4.1 Employee Responsibilities: An injured employee has legal responsibilities he/she
must meet to establish a claim for compensation.
a. The injured employee must notify supervisory or management personnel about
an on-the-job injury no later than the 30th day after the injury occurs, or if the
injury is an occupational disease, no later than the 30th day after the
employee knew or should have known that the disease might be related to the
employment, even if there is no medical treatment or lost time. The following
forms should be completed:
1. Employee’s Report of Injury
2. Employee’s Election Regarding Utilization of Sick and Annual Leave
3. Authorization for Release of Information
4. Witness Statement, if applicable
5. Workers’ Compensation Network Acknowledgement Form, if it was not
submitted at the time of hire
b. In order to receive compensation for an occupational injury or disease, the
injured employee must file with the Texas Department of Insurance, Division of Workers’ Compensation (DWC) a claim for compensation (DWC-41) no
later than one year after the date of injury, or if the injury is an occupational
disease, no later than one year after the employee knew or should have known
that the disease was related to the employment. The DWC-41 is sent to the
injured employee by DWC upon notification of claim.
c. For the purposes of qualifying for workers’ compensation benefits, the law
requires that an employee who claims a possible work-related exposure to
HIV infection must provide a written statement of the date and circumstances
of the exposure. The law also requires the employee to document that, within
10 days after the date of the exposure, the employee is tested for HIV.
d. If medical treatment is required, the employee can seek treatment at any
hospital emergency room. In the event of non-emergency medical treatment,
the employee should seek treatment with a health care provider within the
Health Care Network.
e. If lost time in anticipated, the Employee’s Election Regarding Utilization of
Sick Leave form must be completed. If an employee is absent due to a workrelated injury/illness, he or she shall notify their immediate supervisor and the
UHD Benefits staff at the beginning of the first day’s absence. Upon returning
to work, the employee shall provide the UHD Benefits staff with a copy of the
Physician’s Release to Work prior to resumption of normal duties.
f. Employees must apply for Family and Medical Leave (FMLA) if the
employee has been absent from work due to a work-related job injury for
more than three (3) business or normally- scheduled work days. Please refer to
the Family and Medical Leave Policy.
4.2 Supervisor’s Responsibilities:
a. If the injury is serious/life threatening, the employee’s supervisor is
responsible for assisting the employee in obtaining medical help as quickly as
possible. If the injury is not serious/life threatening the injured employee
should seek treatment with a health care provider within the Health Care
b. Supervisors must be familiar with university policies and procedures related to
workers’ compensation, including forms for which the supervisor and
employee are responsible for completing and/or submitting to the UHD
c. Immediately notify the UHD Benefits staff and the Environmental Health and
Safety (EHS) staff of an employee’s work-related injury, illness or
occupational exposure and complete the Supervisor’s First Report of Injury.
d. Ensure that all appropriate forms are completed and returned to the Benefits
e. Notify the Benefits staff if the employee loses time due to an occupational
work-related injury or illness.
f. Require return to work authorization from the Benefits staff before allowing
employee to return to work.
g. Notify the Benefits staff if the employee resigns, retires, or is terminated while
on workers’ compensation leave.
4.3. Benefits Staff Responsibilities:
a. Assist supervisors and other members of the university community upon
notification of an employee’s work-related injury, illness or occupational
b. Furnish copies of accident forms to the Environmental Health and Safety
Office staff upon notification of an employee’s work-related injury, illness or
occupational exposure so that follow-up investigations can be conducted as
necessary to ensure safe work practices and safe working conditions
c. Review accident forms for completeness and electronically file the
Employer’s First Report of Injury or Illness forms with SORM.
d. If there is treatment or lost time, convert status from incident only to a claim
prior to submitting the accident forms to SORM.
e. Complete any supplemental reports, if necessary.
f. Maintain all workers’ compensation claims filed by UHD employees for at
least two years after the claims become inactive.
g. Notify the employee of his or her rights under the Family and Medical Leave
Act and provide information on PS 02.A.11, Family and Medical Leave Policy.
h. Serve as the liaison between UHD, the employee, the supervisor, and SORM.
i. Maintain frequent contact with the employee on workers’ compensation leave.
4.4. Environmental Health and Safety Office’s Responsibilities:
a. Once notified of an accident, the Environmental Health and Safety Office staff
will secure the site, if possible, and begin the investigation to determine cause
and other factors that contributed to the incident/accident.
b. Obtain factual information about the incident.
c. Interview all witnesses and the injured person (if available).
d. Take pictures of the scene as required.
e. Submit a report to the UHD Benefits staff and SORM, if requested.
f. Make recommendation(s) or takes steps necessary to correct or eliminate the
g. Conduct a follow-up investigation to ensure that contributing factors have been
Responsible Party (Reviewer): Vice President for Employment Services and Operations
Review: Every three years on or before October 1st
Signed original on file in Employment Services and Operations
Issue #1: 11/14/03
Issue #2: 11/05/10
Issue #3: 04/20/15
Issue #4: 05/04/17
UH System Memorandum 01.C.03
State Office of Risk Management (SORM)
Texas State Labor Code, Chapter 401, Title 5, Workers’ Compensation (Texas Workers’Compensation Act)
Texas Workers’ Compensation Work Status Report/Physician’s Release to Work (DWC-73)
Authorization for Release of Information (SORM-16)
Employee’s Report of Injury (SORM-29)
Witness Statement (SORM-74)
Employee’s Election Regarding Utilization of Sick Leave (SORM-80)
Supervisor’s Report of Accident
Workers’ Compensation Network Acknowledgement Form
Texas Department of Insurance, Division of Workers’ Compensation (DWC)
PS 02.A.11, Family and Medical Leave Policy