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Change in employment status includes return to work, discontinuance of work, increase or decrease of regular hours of work and increase or reduction of wages.

Use this form to claim out-of-pocket expenses related to your injury or illness.

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.

This form allows health care providers who have treated your previous injuries to release information to your employer’s workers’ compensation insurer.

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.

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.

This letter from the City of New York Law Department can serve as proof that teachers and other pedagogues are not covered by New York State Workers' Compensation Law and instead are covered under the Line of Duty Injury provision in the DOE-UFT contract. 

This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.

Complete this form to claim disability benefits only if your Workers’ Compensation claim has been rejected.

You should submit this report with your Educational Paraprofessional Leave Application to prevent the disruption of your major medical insurance.

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.

Guide to Workers' Compensation from the UFT Safety & Health Department

Legal referrals injury claim form

The amount of weekly benefits you receive during your period of disability is based on the average weekly wage you were earning at the time of your injury. Initially, you should receive approximately 2/3 of your wages. However, the workers compensation law limits the total amount of benefits you can get.

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.

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.

The DOE will reimburse you up to $500 per school year for stolen or destroyed property such as loss or damage to personal clothing and personal accessories. For reimbursement of eyeglasses damaged in assault cases, use form OP 505G.

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 $1,500.

This circular consolidates and updates the Department of Education’s policies and procedures on line of duty injuries for pedagogical employees previously detailed in Special Circular No. 32, 1989-90: Personnel Memorandum No. 19, 1986-87 and Personnel Memorandum No. 39, 1989-90.

This memorandum supersedes Personnel Memorandum #51, 1997-98. It is the policy of the NYC Department of Education to provide equal employment opportunity to all qualified individuals with disabilities. Any current or prospective employee who is a qualified individual with a disability may request a reasonable accommodation in order to assist in performing the essential functions of his/her present assignment.

Use this confidential form to notify the UFT School Safety Department if you have been the victim of an incident and/or injury. Or fill out the online incident report form.

Complete this form and file it with your school payroll secretary within 10 days.