Worker’s Compensation Claims

To begin a Worker’s Compensation Insurance claim, please complete the appropriate forms (below) for either The University of Texas Health Science Center at Tyler (UTHSCT) or East Texas Quality Care Network (ETQCN).

  • Employees who are injured or who have a hazardous exposure must complete the “First Report of Injury” form and the “Network Acknowledgement” form for every injury/exposure.
    • First Report of Injury
      • The First Report of Injury should be completed (all blanks filled in) and signed by the employee, if he or she is able to complete the form.
      • If an employee is unable to complete the form, his or her supervisor must complete the form for the employee.
      • The First Report of Injury must be received in Human Resources (HR) within 24 hours of injury.
    • Network Acknowledgement
  • Both forms must be forwarded to Lonelle Taylor in HR.
    • Forms may be completed, printed, signed, scanned and e-mailed to or faxed to 903-877-7729.
    • If the First Report of Injury is completed by the supervisor, it can be forwarded to HR without the Network Acknowledgement Form.
    • The employee/supervisor must report any time missed to HR after the initial injury date.
  • If the employee needs medical care and …
    • it is NOT an emergency, he or she should call the Occupational Health Clinic at ext. 7930 to make an appointment.
    • it IS an emergency, he or she should go to the ER.
      • He or she should tell the ER it is a workers comp claim so that it gets billed properly.
      • The ER cannot provide follow up care. Therefore, if follow up care is needed, the employee should make an appointment with Occupational Health Clinic for follow up.

If you have any questions about workers comp please call:

Lonelle Taylor at ext. 7743, or

Kevin Palmer at ext. 2854.

Employee Forms

Please Complete BOTH Forms

Employer’s First Report of Injury or Illness

UT W/C Network Acknowledgement Form

Employee Forms

Please Complete BOTH Forms

Employer’s First Report of Injury or Illness

TX Mutual W/C Network Acknowledgement Form

Contract and agency employees (other than ETQCN employees) who are injured on the job 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.