Online Forms - State of Connecticut Workers 2026

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

Start filling out your form today for free on our platform!