DMHAS: HRD-Workers Compensation

Human Resource Department

Worker's Compensation Unit
Fax (860) 622-2927


Harlynn Jackson, HR Associate, (860) 262-6742, Fax: (860) 730-8366

Betsy Riley, HR Associate (860) 262-6712,

Injury Reporting Hotline: 1-800-828-2717

Forms for reporting a work related injury:

1. WC Injury Reporting Forms:

2.  Directories:

3. Miscellaneous WC Forms:

      • Mileage Worksheet
        Mileage Worksheet to be completed for each medical appointment, including physical therapy. The mileage is for round trip travel to and from the appointment, either to and from home, or work. The completed form is sent directly to your Claims Adjuster at GAB Robins.

      • Verification of Medical Appointment Form
        Verification of Medical Appointment to be completed for each medical appointment, including physical therapy, and either attached to the time sheet when the appointment occurred, or faxed directly to the DMHAS Workers' Compensation Unit. If the appointment occurs during work, you will be paid for this appointment thru payroll. If the appointment occurs after work, payment will be issued from GAB Robins. This form is not to be used during periods of disability.

      • Record of Employment Contact Form
        Record of Employment Contact Form is to be used only when an employee is given a light duty work capacity, and the employer is unable to accommodate the restrictions, or find suitable work within the restrictions given. This form must be completed and submitted to GAB Robins in order to receive Temporary Partial benefits only.

4. Winter Safety Tips:   

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Content Last Modified on 5/25/2017 9:10:46 AM