Workers’ Compensation

The University of Texas at Dallas will comply with the Texas Workers’ Compensation Act as it applies to The University of Texas System, while providing quality customer service to all UT Dallas employees who have been injured on the job and their departmental representatives. If you are injured and need to file a claim, please download and complete the following forms. To ensure full coverage all treatments should be received at an approved medical facility.

Forms

• Employee’s Report of Injury (pdf)
• Network Acknowledgment (pdf)
• Supervisor’s Investigation (pdf)
• Witness Statement (pdf)
• WCI 23 Leave of Absence (pdf)
• WCI 23 Police (pdf)

Resources

• UTD Workers’ Compensation Guidelines (pdf)
• IMO Notice of Network Requirements (pdf) – English
• IMO Notice of Network Requirements (pdf) – Spanish
• IMO Network Employee Handbook (pdf) – English
• IMO Network Employee Handbook (pdf) – Spanish
• Find a Network Provider
• Summary Guidance (pdf)
• Detailed Guidance (pdf)
• Employee Rights and Responsibilities (pdf)
• Texas Department of Insurance Workers’ Compensation
• IMO Telemed Services (pdf)
• IMO Telemedicine Employee Process (pdf)
• IMO Telemed Questions and Answers (pdf)
• RX Bridge Pharmacy First Fill Program (pdf)
• ID Card (png)

Contact

Please send questions and completed forms to: WCI@utdallas.edu  

Your Rights Under Workers’ Compensation

1. You may have the right to receive benefits. You may receive benefits regardless of who caused or helped cause your injury. You may not receive benefits if your injury occurred while you were intoxicated, you injured yourself intentionally or while unlawfully attempting to injure someone else, you were injured by another person for personal reasons, you were injured while voluntarily participating in an off-work activity, you were injured by an act of God, or your injury occurred during horseplay.
2. You have the right to receive the medical care reasonable and necessary to treat your work-related injury or illness for the rest of your life.
3. You have the right to the initial choice of doctor. You may not change doctors except with the approval of the Commission. You do not need to get approval to go to a different doctor for emergency treatment, if you or your doctor moves or if your doctor is unable to continue treating you.
4. You have the right to hire an attorney to help you get benefits or to help you resolve disputes.
5. You have the right to receive assistance from appropriate, qualified Commission staff and, in the event of a dispute resolution proceeding, from a Commission ombudsman free of charge. To request assistance, contact the field office handling your claim, or call 800.252.7031. You have the right to receive information and assistance regarding your claim. Commission staff will explain your rights and responsibilities under the Texas Workers’ Compensation Act. Additionally, you have the right to be assisted by a Commission ombudsman in informal dispute resolutions and in administrative proceedings if you are not represented. However, an ombudsman cannot serve as a legal representative or attorney for you.
6. You have the right to confidentiality. Only people who need to know — such as your doctor, your employer or your employer’s insurance carrier — may see information in the Commission’s files. A prospective employer may get limited information from the commission from the commission about your claims. If you wish someone who is assisting you to have access to your file, you must provide written approval for them to do so.