Worker's Compensation
  • IT IS VERY IMPORTANT TO REPORT AN INJURY AS SOON AS IT OCCURS
  • IF THE INJURY IS SEVERE PLEASE CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM
  • COMPLETE THE PAPERWORK TO REPORT YOUR INJURY AND SEND TO GINA VAN GORDEN, PAYROLL & BENEFITS SPECIALIST AT THE ADMINSTRATION OFFICE
  • PLEASE CONTACT THE PAYROLL & BENEFITS DEPARTMENT WITH ANY QUESTIONS OR ISSUES AT (570) 638-2183 EXT. 302 OR BY EMAIL AT gvangorden@southerntioga.org  

 


For an injury you will need to complete the following forms:
  • Employee Accident Report
  • Panel of Physicians (Please read, sign and make yourself a copy of this form)
  • Medical Treatment Waiver Form (Please sign this form if you will not need medical treatment)
If you need medical treatment, please complete the following forms:
  • Employee Accident Report
  • Panel of Physicians (Please read, sign and make yourself a copy of this form)
  • Authorization for Disclosure of Health Information
  • Employee Questionnaire

Take with you to your appointment the following forms for your physician to complete:

  • Work/Activity Status Form