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Safety Forms

 

Risk Management (RM)/Workforce Safety Insurance (WSI)

The VCSU Safety Office must report any incidents, no matter how small, to Risk Management. Please determine the type of incident and fill out the appropriate form. These forms need to be filled out for employees, students, and visitors on campus. Once the form is complete, please turn in to the Safety Office.


All Incident Reports MUST be turned in to the Safety Office within 24 hours of the incident.
 
VCSU Initial Incident Report
 
 
RMP Incident Report
 
 
VCSU Near Miss Report
 
 
RMP Motor Vehicle Accident Report
 
 
 
WSI encourages workers and employers to immediately file a claim. Under North Dakota law, employees must notify their employer of the injury within 7 days after an accident or when the injury became apparent.


All WSI Claims SHOULD be turned in to the Safety Office within 24 hours of the incident.
 
WSI Claim Form
 
 

Designated Medical Provider

We are participating in the Risk Management Workers Compensation Program. This allows the State to designate health care providers to treat your workplace injuries and illnesses. Workforce Safety and Insurance may not pay for medical treatment to another provider unless you are referred to this provider by the designated medical provider, or unless RMP was in writing prior to the injury that you wanted to be treated by a different medical provider. You must also name your different medical provider. Emergency care is exempt from this designated provider requirement.

For more information contact the Director of Human Resources
Employee Services
 
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Office Information
VCSU Safety Office
Facilities Services
Valley City State University
101 College St SW
Valley City, ND 58072
701.845.7705
800.532.8641 ext. 37705
Fax: 701.845.7707

Director of Facilities Services | Risk Management Contact
Ron Pommerer
701-845-7700

Safety Coordinator
Jessica Frerich
701-845-7710

facility.services@vcsu.edu
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