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UFT Workers' Compensation Intake Form
Workers’ compensation intake form for Paraprofessionals, School Nurses, Occupational and Physical Therapists:
C-2: Employer’s Report
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...
C-3: Employee’s Claim
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.
C-4: Physician’s Report
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.
C-257: Expense Reimbursement Form
Use this form to claim out-of-pocket expenses related to your injury or illness.
DB-450: Disability Claim
Complete this form to claim disability benefits only if your Workers’ Compensation claim has been rejected.
MD-1: Request for Medical Authorization
Here is the form for an attending doctor to obtain medical authorization:
WCD-23: Employee’s Notice of Injury
Complete this form and file it with your school payroll secretary within 10 days.
CAR Transfer Form
All pedagogues and paraprofessionals may use this form to donate sick time to a colleague. The recipient receives one day for every two days donated. Sick leave transfer rules are on page 2 of the form.
OP 160: Leave of Absence Without Pay
All pedagogical personnel may apply for a medical leave of absence without pay only when they have exhausted all of their Cumulative Absence Reserve (CAR) days. This application must be completed, signed and submitted to HR Connect for approval...
OP 255: Resumption of Service Report
Upon an employee’s return from a leave of absence without pay, the payroll secretary must submit an OP 255 form to the Bureau of Salary Differentials and Status.
Chancellor's Regulation C-650: Sabbatical Leaves of Absence
This regulation sets forth the rules governing sabbatical leave of absence applicable to all pedagogical personnel.
Application for Retirement Leave of Absence (Terminal Leave)
Pedagogues and paraprofessionals use this form to apply for a retirement leave of absence. For every two days in the employee’s sick bank, one day of terminal leave is granted. The form must be filed 30 days in advance of the leave. The leave can...
OP 44: Application for Termination Pay for Pedagogues
Upon resignation, termination or retirement, pedagogues are entitled to receive half of their sick leave balance (up to 100 days).
Membership Application (Paraprofessional)
Print and complete the paraprofessional application only if you are not able to use the online enrollment form.
Membership Application (Retired Teachers)
Print and complete the retired teachers’ application only if you are not able to use the online enrollment form.
Membership Application (all DOE titles except paraprofessionals)
UFT membership application for all DOE titles except paraprofessionals. Print, complete and submit this application form only if you are not able to use the UFT's online enrollment form.