4 Summer St., Rm 104, Haverhill, MA 01830 | Office Hours 8:00-4:00 | Phone (978) 374-3411 | Fax (978) 374-3422
Work Injury Reporting – Workers’ Compensation
Injury Forms – School
Instructions/Protocol for reporting work related injuries – Please read this before completing the forms to report an injury. Please forward completed forms, via email to firstname.lastname@example.org or interoffice mail to City Human Resources Office, Room 306, City Hall, for processing. Also, please forward a copy of the forms to Nina Torrisi in the School Human Resources Office, via email to email@example.com.
Form 118 – This form should be completed by someone other than the injured employee. Complete this form if the employee is going to be out for less than 5 work days.
Form 101 – This form should be completed by someone other than the injured employee. Complete this form if the employee is going to be out for 5 or more work days.
Medical Authorization form – Complete this form if you seek medical treatment at a facility other than the Occupational Health Center at Anna Jaques.