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Lost Time Reports must be submitted to University Risk Management every two weeks, even if there is no workers compensation lost time until the case is closed. If you have any questions, please contact University Risk Management at (303) 860-5682. Download the Workers' Compensation Guideline for Supervisors and Payroll Liasons. Click on the ? for Help. This is a SECURE and ENCRYPTED online form.

Print a Blank Form Here Red indicates a Required Field
Workers Compensation Lost Time Report Worksheet
EMPLOYEE NAME
CAMPUS:
Boulder Denver UCCS System
SUPERVISORS NAME
DEPARTMENT NAME
DATE OF INJURY
EMPLOYEE ID#
COMPLETED BY
PHONE NUMBER
CAMPUS BOX:
DATE:
DAY
DATE
(MM/DD/YY)
SHIFT HOURS START
(H:MM) ?
SHIFT HOURS END
(H:MM) ?
NON WC HOURS
?
WC LOST TIME
?
COMMENTS ?
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WEDNESDAY
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THURSDAY
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FRIDAY
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SATURDAY
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WEEK 2            
SUNDAY
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MONDAY
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TUESDAY
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WEDNESDAY
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THURSDAY
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FRIDAY
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It is unlawful to knowingly provide false or misleading information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.