CC form 136-R

You are covered medically under Federal Workers Compensation for injury while traveling to and from, and during ROTC training as long as you are registered as a full-time student and properly enrolled in ROTC. If you are injured during ROTC training and require medical treatment you must (within 10 days) see your ROTC Admin Office to file a claim under Workers Compensation. Delay in filing a claim may affect approval of your case. After reading the form, date , sign and print your First Name, Middle Initial, and Last Name where indicated under your signature.

BYU STUDENTS ONLY: If you are registered for the EXSC 143-R (ROTC PE) class and are injured while participating in physical training and require treatment, you should file a claim against your BYU Student or Private Health Insurance (not with Workers Compensation). If BYU Student Health Insurance is used, you must tell BYU you were injured during a University PE class and not during ROTC training.

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