Worker’s Compensation Claims

If you have an on-the-job injury or exposure, please locate the information below for your employer, The University of Texas Health Science Center at Tyler (UTHSCT) or East Texas Quality Care Network (ETQCN), click on each link and review the information. Complete your employer’s First Report of Injury and Network Acknowledgment forms and email them to: benefits@nulluthct.edu.

  • Employer’s First Report of Injury or Illness: 
    • Used to document the injury. Please provide detailed information about the injury/exposure, body part affected and the physical location where the injury/exposure occurred. You do not need to complete the information related to your employment (lines 30-39).
    • May be completed by an employee’s manager if the employee isn’t physically able to complete the First Report of Injury form.
  • Network Acknowledgment used to:
    • Acknowledge an employee’s understanding of how to obtain care for on-the-job injury or exposures
    • Identify the provider network that needs to be used.

If you have any questions about workers compensation, please call:

Lonelle Taylor at ext. 7743, or

Robby Underwood at ext. 2854.


UTHSCT
Employee Forms/Information

Employer’s First Report of Injury or Illness

Workers Compensation Network Acknowledgment Form

Notice of Network Requirements

 

If you need medical care,

  • Non-emergency care is available through the Occupational Health Clinic at UT Health North Campus Tyler or through one of the network providers listed on the Network Acknowledgment form.
  • Emergency care is available at UT Health North Campus Tyler, but may be obtained anywhere.

Prescription Drug First Fill
(to be used if prescription is prescribed as a result of on-the-job illness).


ETQCN
Employee Forms

Please Complete BOTH Forms

Employer’s First Report of Injury or Illness

Network Acknowledgement Form

If you need medical care,

  • Use the Network Acknowledgment form to locate network providers for Texas Mutual non-emergency care.
  • Emergency care is available at UT Health North Campus Tyler, but may be obtained elsewhere.

Texas Mutual Prescription Drug First Fill
(to be used if prescription is prescribed as a result of the on-the-job injury or illness).


Contract and agency employees (other than ETQCN employees) who have an on-the-job injury or illness need to contact their employer directly regarding a workers compensation injury. The forms provided on this website may not be used to report employee injuries to a contracting employer.