Forms

Accidents and Injuries

The following is a list of basic forms to complete. Access all required forms from the HR Workers Compensation website (https://hr.unl.edu/workerscomp/ ), Folder with All Forms button. For questions regarding these forms contact UNL’s Human Resources Worker’s Compensation Administrator (402.472.8414 or workerscomp@unl.edu).

• First Report of Alleged Occupational Injury or Illness
• Release to Return to Work
• Supervisors Incident Analysis Report
• Employee Incident Report
• Witness Report

Audits and Surveys

See Safety Audit Guidelines SOPs

Biosafety

• Autoclave Log Sheet
• Biosafety Manual Table of Contents Form

Bloodborne Pathogens

• Declination Statement (EHS-BBP-02) (5/20)
• Enrollment Checklist and Site-Specific Training Roster (EHS-BBP-04) (5/20)
• Exposure Care Kit (EHS-BBP-03) (5/20)

Laser Safety

• Specific Training Form (Practical) for Class 3B and Class 4 Laser Devices and Systems

Radiation Safety

• Declaration of Pregnancy 
• Radiation Training & Experience History and Personal Dosimetry
• Specific Training Form (Practical) for Non-Healing Arts Radiation-Generating Devices
• Specific Training Form (Practical) for Portable Gauge Users
• Specific Training Form (Practical) for Sealed Source Users

Respiratory Protection

• Medical Qualification Questionnaire (EHS-RPP-04) (4/24)
• Medical Surveillance Assessment (EHS-RPP-05) (4/24)