Online Forms - State of Connecticut Workers Preview on Page 1

Online Forms - State of Connecticut Workers 2026

The document is an Occupational Injury or Illness Employee Report that requires employees to provide detailed information about their injury or illness, including the nature of the injury, when it was first noticed, and any relevant medical history. It includes sections for describing the pain, indicating body parts affected, and documenting any medical treatment received. The report emphasizes the importance of timely completion for accuracy and includes a declaration statement for the employee to affirm the truthfulness of their responses.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Employee Name at the top of the form. This is essential for identifying your report.
In the section labeled 'Explanation of injury', provide a detailed account of how, when, and where the injury occurred.
Fill in the 'Date you first noticed the pain' to help establish a timeline for your injury.
Complete the Employer field with 'Northeastern State University'.
Indicate whether the pain developed gradually or suddenly. If sudden, describe what you were doing at that moment.
List any body parts injured and whether you've discussed this pain with anyone at work.
If applicable, note any recent non-work-related injuries or illnesses and provide details about them.
Use the diagram provided to indicate the location and level of pain you are experiencing, using the specified codes for type and severity.
Answer whether medical treatment away from the job site was offered and sign if treatment was declined.
Finally, declare under penalty of perjury that all statements are correct by printing your name, signing, and providing your date of birth.

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How to file workers comp in Connecticut?

Promptly file a Written Notice of Claim: In Connecticut, you must file Form 30C, which gives notice to the Workers Compensation Commission that you are claiming benefits. Although you notified your employer that you were injured, you must file the Written Notice, Form 30C, as well.

What is a form 30C in CT?

Notice of Claim for Compensation (Employee to Administrative Law Judge and to Employer) The Form 30C is to be completed and filed by a claimant (employee) or claimants attorney/representative for making a claim for workers compensation benefits.

What are the benefits of working for the state of Connecticut?

You generally have one year from the date of the injury to file CT workers compensation claims. However, you should report any work-related injuries or sicknesses to your supervisor or manager immediately. It is best not to wait to file your claim, and the sooner you file your claim the better.

Which is the most common type of workers compensation claim?

Strains and sprains are by far the most common on-the-job injury for workers. Strains and sprains usually happen when employees are carrying or handling materials. According to the Travelers Companies, 1.5 million workers submit workers compensation claims for sprains and strains every year in the United States.

How to file a workers comp claim in Connecticut?

File a formal benefits claim Workers typically need to submit a Workers Compensation Commission Form 30C to begin the formal claims process. Workers have one year from the date of their injury or three years from when a condition began presenting symptoms to perform this step.