Forms

Non-Injury Employment Incidents – Standard Liability Incident Report (Form 001c 06/2019) (pdf)
(To be filled out by SUPERVISOR WITH EMPLOYEE’S assistance)

Personal/Bodily Injury Standard Liability Incident Report (Non-Vehicle Injury) (Form 001be 06/2019) (pdf)
(To be filled out by SUPERVISOR WITH EMPLOYEE’S assistance)

Vehicle and Other Property Standard Liability Incident Report (Form 001a 01/2020) (pdf)
(To be filled out by SUPERVISOR WITH EMPLOYEE’S assistance)

Scope of Employment (pdf)
(To be filled out by SUPERVISOR, not Employee)

Workers’ Compensation Incident Investigation Report (pdf)
(To be filled out by SUPERVSIOR, not Employee)

Rogers State University is Agency #461

Procedures

In the event of a workplace injury, the first priority is to seek medical treatment for the injured employee, if needed. All incidents must be reported to the Office of Human Resources as soon as possible.

If injury is life threatening, call 911 for emergency medical treatment.

  • Steps 3 – 6 below should be followed as soon as reasonably possible.

For non-emergency injuries, the following steps should be followed:

Step 1:
Employee should notify his or her supervisor as soon as the injury occurs (prior to seeking medical treatment).

Step 2:
Supervisor will refer injured employee to the Student Health Center. Should the injury require additional medical attention or occur outside normal office hours, the employee will be referred to one of the Participating Providers below:

Claremore:
Access Medical Center Blue Starr
401 W Blue Starr Dr.
Claremore, OK  74017-4006
(918) 343-1600

Ascension St. John Urgent Care Claremore
1910 South Falcon Ave.
Claremore, OK  74019
(918) 343-6855

Bartlesville:
Access Medical Center 
Located near Washington Park Mall 
2334 SE Washington Blvd, Ste B
Bartlesville, OK 74006 
918-331-9184

Pryor:
Access Urgent Care
4111 Redden
Pryor, OK  74361
(918) 825-7555

Step 3:
Employee must complete the Authorization for Release Form (doc) and return it to the Human Resources Office. 

Step 4:
Employee should take the Return To Work Form (docx) to the provider. Employee will be required to return the completed form upon his or her return to work.

Step 5:
Employee should follow the instructions on the First Script Form (pdf) to fill related prescriptions at no cost.

Step 6:
Supervisor will complete the Incident Investigation Report (pdf) and return to Human Resources within 24 hours of the incident. Prompt reporting of the injury is imperative to ensure the employee receives proper approval for treatment.