Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the document and open it in the required editor.
2. In Section A, provide the patient information including the employee's first and last name, employee ID number, supervisor's name, signature, today's date, employee's phone number, supervisor's phone number, and the date and time of the injury.
3. For injuries within Wake County, direct the employee to one of the authorized treatment facilities. Ensure to include necessary details for prescriptions, if applicable.
4. In Section B, the medical provider should fill in the diagnosis, treatment details, and any medications prescribed.
5. In Section C, indicate the work status information. Specify whether the patient can return to work with or without restrictions or is unable to return until a follow-up.
6. In Section D, provide detailed work restrictions, including posture, movement, and lifting or carrying limitations, if any.
7. In Section E, document any follow-up appointment particulars, including date and time.
8. Ensure the medical provider signs the document and dates it appropriately.
9. Finally, send the completed report to both HR Benefits and Environmental Health & Safety, ensuring it is submitted within 24 hours of the incident.

Complete your NCSU Supervisor’s Medical Treatment Authorization form online today for seamless processing.