Workers’ Compensation

Compensation For Work Related Injuries

Workers’ Compensation Insurance coverage is a program created by State Law that provides medical, rehabilitation, income, death and other benefits to employees and dependents due to injury, illness and death resulting from a work-related incident. For more information regarding Workers’ Compensation, please see the following links:

On-the-Job Injury Reporting Procedures

Workers’ Compensation Forms 

To be completed by the injured employee’s supervisor:

GSU Modified WC-1 Form


To be completed by the injured employee:

Employee Accident Statement Form 

Leave Election Memorandum Form

Accept/ Decline Benefits Form


To be completed by anybody who may have seen the incident occur:

Accident Witness Statement From



GSU Temporary Prescription Form


Additional Information:

Workers’ Compensation Posted Panel of Physicians – MCO

Workers’ Compensation Employee Bill of Rights Poster – English | Spanish