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Workers' Compensation and Leave
The City and County of Broomfield is committed to providing a safe work
environment for its employees, volunteers and contractual persons.
If you are injured on the job:
- Complete First Report of Injury (required) - all injured employees must complete this form and give it to Human Resources within 24 hours of the accident. If the employee is unable to complete it, a supervisor must complete
it, and have the employee complete his/her own when he/she is able. - Choice of Provider Letter (required) - all injured employees MUST review to understand there are two choices for care after a workplace injury.
- Accident Investigation - for workers' compensation injuries only, please see the Risk Management page for non-workers' compensation reporting.
- Exposure Incident Investigation and Post-Exposure Checklist
Leave
The City and County of Broomfield offers a variety of leave options for eligible Full-Time and Part-Time employees.
FMLA General Notice for Employees
Leave Policies
- Full Time Employees Leave Policy
- Part Time Employees (PT) Leave Policy
- Part Time Non-Benefited (PP) and Temporary Employees Leave Policy
- Return to Work/Modified Duty Policy
Leave Request Forms
- Family and Medical Leave Request – Employees who are requesting leave must complete this form and give to his or her supervisor for their signature and return to Human Resources.
- Certification of Health Care Provider Form
- Requesting Leave for Yourself – Must be completed by the employee’s physician and review his/her job description for an employee’s own serious health condition
- Requesting Leave for a Family Member - Must be completed by family members physician
- Short Term Disability eligibility is determined by Harford. Employees may call Hartford to start the application processes over the phone click here Leave Request Forms Leave Request Forms for details.
- Release to Return to Work Form – must be completed by employee’s physician and review job description prior to returning to work.
- Access to Job Descriptions (must be reviewed by physician during completion of forms)
- Certification for Care of Current Service member's Serious Injury or Illness
- Certification for Care of Veteran Serious Injury or Illness
- Certification for Qualified Exigency for Military Family Leave
- Leave Donation Request Form
- Kaiser Authorization to Disclose Health Information Form
- Employee's Guide to the Family and Medical Leave Act
- Request for Domestic Abuse Leave form
Related Policies:
Workers Compensation Policy and Procedures
Seat Belt Policy
Bloodborne Pathogens
Electronics Recycling and Surplus Disposition
PPE Guide
Driver Evaluation Form
Chemical Hygiene Plan
HHSD Exposure Control Plan
Hazard Analysis of Broomfield Environmental Services and Field Operations
Wastewater Confined Space Policy
Water Plant Confined Space Policy
Utilities Confined Space Policy
Seat Belt Policy
Bloodborne Pathogens
Electronics Recycling and Surplus Disposition
PPE Guide
Driver Evaluation Form
Chemical Hygiene Plan
HHSD Exposure Control Plan
Hazard Analysis of Broomfield Environmental Services and Field Operations
Wastewater Confined Space Policy
Water Plant Confined Space Policy
Utilities Confined Space Policy