Cicero School District 99

ACCOMODATION REQUEST

Employees requesting workplace accomodations due to their own medical condition or disability must submit the following forms to: hr_accomodations@cicd99.edu

• Employee Accomodation Request Form (Completed By The Employee)
• Physican Request For Information Form (Completed By A Licensed Physician)

IMPORTANT NOTES:

• This request applies only to the employee’s medical condition and not to acommodations for high-risk family members or childcare/school closures.
• Employees must provide detailed information on how their condition impacts their job duties and what accomodations are needed.
• A physician’s certification is required, verifying the medical necessity of the request and suggesting reasonable accomodations. 

EXAMPLES OF QUALIFYING ACCOMODATIONS INCLUDE (BUT ARE NOT LIMITED TO):

• Need for specific products, equipment, or software to perform job duties
• Adjustments to work schedules due to medical limitations

WORKERS’ COMPENSATION CLAIM KIT & FILING PROCEDURES

If you experience a work-related injury, follow these steps immediately to ensure proper reporting and processing of your claim.

Download This Claim Kit

STEP 1: REPORT THE INJURY IMMEDIATELY

• All injuries, no matter how minor, must be reported to your supervisor within 24 hours.
• Employees should verbally or in writing notify their direct supervisor or the person in charge of the facility.
• Supervisors must then notify Tina Cruz at (708) 863-4856 ext. 68091 or tcruz@cicd99.edu so the claim process can begin.

STEP 2: COMPLETE REQUIRED FORMS

After reporting the injury, the following forms bust be completed:

Employee Responsibilities:

• WC Employee Injury Report (Page 9) – Employee must describe the incident in detail, including exact body parts affected.
• Authorization For Release Of Health Information (Page 10) – Employee must sign this to allow processing of medical information (if refused, the supervisor must note it on the form)
• Injured Worker Responsibilities Form (Page 4) – Employee acknowledges their responsibilities during the claim process

Supervisor Responsibilities:

• WC Supervisor Report (Page 7-8) – Supervisors must complete this form independently and in their own words.
• Employer’s Authorization Form For Woodlake Occupational Health (Page 5) – If the employee seeks treatment at Woodlake, this form must be completed and provide to the employee.
• Accident Investigation (Page 2-3) – Supervisors must review the incident location, details, and determine if safety precautions were followed.

Witness Responsibilities (If Applicable):

• WC Witness Report (Page 11) – Any employee who witnessed the incident must complete this form and provide their account

STEP 3: SEEK MEDICIAL TREATMENT (IF NEEDED)

Minor Injuries: First aid can be administered at the workplace.

Serious Injuries: The employee must seek treatment at:

• Woodlake Occupational Health – 1111 Superior St., Suite 506, Melrose Park, IL 60160 | Phone: (708) 919-9900 | (708) 919-9901
• The nearest emergency medical facaility or their own doctor

Employees must submit a Fully Duty Release from their doctor before returning to work. The release must be sent to Tina Cruz

STEP 4: SUBMIT ALL FORMS WITHIN 24 HOURS

• All reports (Employee, Supervisor, and Witness) must be sent to Tina Cruz within 24 hours of the incident.
• Email scanned copies first, followed by the originals via interschool mail.
• Failure to submit forms on time may result in delays in salary reimbursement (if applicable).

STEP 5: CLAIM PROCESSING & FOLLOW UP

Once submitted, Tina Cruz will forward the claim to the Workers’ Compensation Claims Administrator (IPMG).

If claim is approved, medical bills should be sent directly to:

• IPMG, 225 Smith Road, St. Charles, IL 60174
• Phone: (877) 616-0504 | Fax: (630) 587-7755

Alternatively, employees may bring bills to Tina Cruz at the administration building.

STEP 6: FINAL REMINDERS

• Submitting a claim does not guaruntee approval. All claims will be investigated.
• Incomplete forms will be returned, delaying processing.
• Employess are expected to follow all workplace safety procedures to prevent injuries
• For any questions regarding workers’ compensation, contact Tina Cruz at (708) 863-4856

Thank you for your cooperation in ensuring a safe workplace.