Form C-1 - Notice Of Injury Or Occupational Disease

The C-1 is completed by the injured employee or supervisor for all accidents and injuries.

  • Complete the C-1 form and the Supervisor's Injury/Illness/Incident Report Forward both documents to Risk Management & Safety via UNLV Secure File Transfer or fax (702-895-5227).
  • CSN, NSC, and external email users without a “@unlv.edu” email can register for an account to send secure files.
    • Click “Log In to Secure File Transfer” box and follow the instructions.
  • After you log in to the UNLV Secure File Transfer website, email the documents to workerscompforms@unlv.edu. Add the worker’s name in the “Message” box.
  • It is important that you securely email any document containing HIPAA and PII information, including the C-1.
  • The C-1 must be submitted within seven days from the date of the accident. NRS 616C.015

Form D-2 – Brief Description Of Your Rights and Benefits If You Are Injured On The Job

The D-2 form provides basic information of your rights and benefits relating to workers' compensation pursuant to NRS 616C.050.

Download and print a copy for the employee to retain for their records.

Form C-4 – Employee’s Claim for Compensation/Report Of Initial Treatment

  • C-4 will be filled out and completed at the medical facility. It is not necessary to download this form.
  • Inform the medical provider that you were injured at work.
  • The C-4 form starts the workers compensation claim process.
  • The employee has 90 days from the date of injury to seek medical treatment. (NRS 606C.020)
  • The bottom half of the C-4 must be completed and signed by a medical provider.
  • The medical provider will give you a copy of this form and will forward a copy to the workers' compensation office and/or the third-party administrator. NRS 616C.040.
  • If you are treated at a medical facility that is not on the approved workers compensation provider list, be sure to check with the workers' compensation office to ensure that the C-4 form has been received from the out of network facility.
  • Your claim cannot be processed for a workers’ compensation claim without the completed C-4 form.

Supervisor's Injury/Illness/Incident Report

The employee’s supervisor completes the "Supervisor's Injury or Illness Incident Report” form immediately after being notified of a work-related accident or incident and forwards it to the Occupational Safety and Health and Risk Management & Safety Office.

Workers’ Compensation Witness Form

Fax the completed form to 702-895-5227 or email to workerscompforms@unlv.edu.