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Human Resources

Workers' Compensation

City of Henderson C1 Form

Had an on-the-job injury and need to fill out a C1 Form?
Follow the link below to open the PDF fillable form.  Instructions can be found to the right. 

Refer to your "wallet card" for treatment locations or contact your supervisor.

You may also contact Amy Wong (ext. 1921) or Mary Sexton (ext. 1922) if you have any questions.

 

First Notice of Injury/C1 Submittal Process

This form only applies to City employees and volunteers
  1. Complete the pdf-fillable C1 form (left).  All fields must be completed.  
  2. Print a copy of the form for signature. Save a copy for your records if you wish. Bring the hard copy to your supervisor for additional processing.
  3. Obtain supervisor signature on the hardcopy of the completed C1 form (and any other forms, if appropriate) and interoffice it to Risk Management, MSC 137.  
  4. Risk Management and/or Safety Representatives will be in touch for further information and instruction.