WCI Form-23 Instructions
WCI Form-23
Revised 5/2020
Employee Instructions
Injured employees may elect to use accrued sick leave and all, some, or none of their other available leave for time missed from work due to the
work-related injury. Accrued sick leave and other available leave are the amounts of paid leave available at the time of injury. The following
information details the effects of the different choices available to you.
If You Choose Option 1- Paid Leave
• You must use all accrued sick leave but may elect to use all, some, or none of your other available leave.
• All sick leave must be exhausted before other available leave may be used. Once sick leave is exhausted, you will be asked to make an
election regarding other available leave.
o If you select 1A and return to work but later have additional days of disability, you must use any accrued sick and other
available leave before receiving workers’ compensation income benefits.
o If you select 1B, you must use any sick leave balance and can elect to use any hours of other available leave before receiving
workers’ compensation income benefits. Upon exhaustion of this choice, you may elect to use additional available leave to
remain on the payroll.
o If you select 1C, you must use any/all accrued sick leave before receiving workers’ compensation income benefits.
Leave exhaustion- For the purposes of entitlement to income benefits, sick leave shall be considered exhausted when remaining sick leave
hours are insufficient to cover a full work shift. Sick leave can be used in conjunction with other paid leave to cover a full work shift if other
paid leave is elected by the employee. Other paid leave shall be considered exhausted when remaining leave hours are insufficient to cover
a full work shift.
• Workers’ compensation income benefits do not begin until the eighth day of disability. Employees who are disabled for at least 14 days
will receive retroactive benefits for any portion of the seven-day waiting period not paid by leave. Note: "Disability" means the inability
because of a compensable injury to obtain and retain employment at wages equivalent to the preinjury wage.
• You will continue to receive your full pay if you have available leave and have authorized your institution to use it for your injury. If your
elected leave is exhausted, you may receive income benefits to replace a portion of your lost wages. This may be 60%, 70%, or 75% of
your average weekly wage depending on your employment status and wages at the time of your injury.
• It is recommended that you consult with your Human Resources department (leave management) to discuss the impact of your election
on leave balances and insurance benefits should you be off work for an extended period.
If You Choose Option 2
• You choose to not use any sick or other available leave for your compensable injury, you will be immediately placed on leave without pay
for all lost days.
• You will not be eligible to receive any workers’ compensation income benefits for the first seven (7) calendar days you are unable to
work. If eligible, TIBs will begin on the 8th day of disability and employees who are unable to work for 14 days will receive retroactive
payment of benefits for the first seven days. You will be paid at a rate of 60%, 70%, or 75% of your weekly wage depending on your
wages at the time of your injury.
Employer WCI Representative Instructions
• In the office use section, you or a department timekeeper enter the employee’s leave balances and as of date.
• Leave fields should include ALL available sick leave or other available leave to the employee via the institution, other than sick. This could
include vacation, compensatory time, etc.
• The first full workday covered by sick or other leave will be the first full day lost from work following the date of injury. Do not list the
date of injury in this field. If no sick or other leave is available, enter ‘0’ in the related field.
• Leave exhaustion dates:
o For sick leave, calculate and enter the last full workday that sick leave will cover the employee’s work absence, based upon
employee’s regular work schedule.
o For other leave elections, begin with the next workday following sick leave exhaustion and calculate the last full workday other
leave hours will cover the employee’s work absence, using the employee’s regular work schedule.
o Leave without pay (LWOP) date is the date the employee is to be removed from the payroll and placed on LWOP.
