This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.
Forms for Injured on the Job
Most of the forms below are PDF files. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.
Injury in the Line of Duty
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This form is used by all pedagogues to apply for medical certification for absence up to 20 consecutive school days, for requests to borrow sick days, for excuse of absence due to children’s diseases, and for injury in the line of duty claims. Rules and instructions are on page 2.
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This legal form, which must be notarized, states that if you sue the DOE and win, you will return the money paid to you in salary for the period of your absence.
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All pedagogues, paraprofessionals and administrative staff are required to submit an OP 407 when applying for sabbatical leaves, for restoration of health leaves, for sick leaves over 20 consecutive school days and for alleged line of duty injuries. To maintain confidentiality, this form may be submitted directly to the Medical Bureau in place of a doctor’s statement on an OP 198 form.
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The DOE will reimburse you up to $100 for stolen or destroyed property, but only if the property is of the type that is normally brought into school. For reimbursement of eyeglasses damaged in assault cases, use form OP 505G.
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Once line-of-duty status has been approved, you can use this form to request reimbursement for out-of-pocket medical expenses to a maximum of $750.
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If you have been assaulted, you should use this form in place of the standard OP 505 to request reimbursement for out-of-pocket medical expenses. The $750 limit on reimbursements may be waived by the Department of Education in assault cases.
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Use this confidential form to notify the UFT School Safety Department if you have been the victim of an incident and/or injury. Return the form to your chapter leader as soon as possible.
Workers' Compensation
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In order to reopen a claim more than seven years after an accident, this form must be filed immediately with the chair of the Workers' Compensation Board, together with the attending doctor's report (form C-27) if required, at the district office at which the case was closed.
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Use this form to claim out-of-pocket expenses related to your injury or illness.
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Payroll secretaries should follow these instructions to correctly file the C-2: Employer's Report form.
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The employer is required to fill out this report within 10 days to notify the Workers’ Compensation Board of your work-related injury or illness. You should not participate in filling out this form. See the C-2: Employer's Report - Filing Procedure for further instructions.
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This form allows health care providers who have treated your previous injuries to release information to your employer’s workers’ compensation insurer.
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You must fill out this form to initiate your Workers’ Compensation claim. You should retain one copy, file a second with the Board, and provide a third to your legal representative.
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Your doctor must fill out this form at regular intervals — usually every 4-6 weeks — during your convalescence. It is used to determine your level of benefits — so it is very important that your doctor fills it out carefully.
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This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.
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Complete this form to claim disability benefits only if your Workers’ Compensation claim has been rejected.
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You should submit this report with your Educational Paraprofessional Leave Application to prevent the disruption of your major medical insurance.
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Educational paraprofessionals should use this form for initial requests for leaves of absence as well as requests for extensions. Requests for extensions must be submitted prior to the date of expiration of the current leave.
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Complete this form and file it with your school payroll secretary within 10 days.