The following is intended as a sample for procedures and guidelines for Injury-Illness Reporting for Workers' Compensation. Your company should create a procedure for handling claims. Consult your policy and other requirements as needed.

Injury-Illness Reporting Workers' Compensation

Department of Industrial Relations

Workers' Compensation Employer's Report of Occupational Injury or Illness

Employee Claim Form for Workers’ Compensation benefits

State Fund

If you are with State Fund use this Employer's form. Or go to this link for the complete Claims Kit.

DEFINITION

First Aid Cases: The definition of a first aid case is any one-time treatment of minor scratches, cuts, burns, splinters, or other minor industrial injury which do not require medical care. In the California Labor Code section 5401 regarding treatment for injury that is NOT First Aid it states, "which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid". This is further clarified in the code as, "As used in this subdivision, "first aid" means any one-time treatment, and any followup visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and followup visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel."

Note: As of January 2017 the requirement for reporting First Aid has changed. The clarification states, "There are no special or unique coding requirements related to the reporting of claims meeting the Labor Code Section 5401(a) definition of first aid. The reporting requirements in Part 4 of the USRP applicable to the reporting of medical costs incurred on any other medical only claim also apply to the medical costs incurred on claims meeting the first aid definition. "

If the injury results in lost time from work beyond the employee's work shift then the injury would no longer be first aid and a claim form must be provided to the employee.

SAMPLE POLICY

• When an accident or injury occurs on the job or at the job site, the incident must be reported within 24 hours of knowledge of the occurrence. It is imperative that forms be provided to the employee and his/her supervisor for completion and submission within one working day of the incident.
• Provide for appropriate medical treatment immediately!
• A Workers' Compensation Employee's Claim Form must be provided to the employee and a Employer's Report of Occupational Injury or Illness form MUST be completed within ONE working day if, as a result of a work-related injury or illness, the employee:
  1) requires medical treatment beyond first aid; or
  2) returns to work with temporary medical restrictions; or
  3) loses time from work on any day after the date of injury; or
  4) obtains care from a private physician; or
  5) requests that a claim be filed.
• Filing the Employer's Report of Occupational Injury or Illness is required by California State Law. It is imperative that this form is completely and accurately filled out to assure that the employee receives proper compensation and medical treatment in the event of an industrial injury or illness. Failure to file this form in a timely manner may place your business in violation of State Law and make it subject to monetary penalties.
• Serious exposure to a hazardous substance should always be reported.
• For first aid injuries, an Employee's Claim Form is not required unless specifically requested by the employee.

PROCEDURES

Form 1: Employee's Claim for Workers' Compensation Benefits: This form is not an admission of liability.

• You have ONE WORKING DAY after notice or knowledge of the injury or illness to provide this form to the employee. (This does NOT include minor injuries that require only first aid treatment.)
• If you cannot personally provide the form to the employee, follow steps A through E below and send the form by first class mail to the employee's home address. On line 12 of the form write "mailed" and the date it was sent.

Instructions for completing Form 1:

• Enter employee's name on line 1, department name on line 9 and University address on line 10.
• Enter date of knowledge of injury/accident on line 11.
• Enter the date the claim form was provided to the employee on line 12.
• Obtain the employee's initials acknowledging receipt of the form on line 12.
• Retain Employer's Temporary Copy for your records and give the form to the employee.

EMPLOYEE: completes the upper box (lines 2-8), and keeps the Employee's Temporary Copy. The employee has the option to complete and return the form OR NOT (employee's choice).

• Give Employee's copy to the employee in person or send via first class mail.

Form 2: Employer's Report of Occupational Injury or Illness Instructions for completing Form 2:

• The form must be completed within one working day of when the employer learned of the injury or illness.
• Complete the WC Connection Contact section of the report form:
  1) employee's name and home phone number and address;
  2) employee's Social Security number, sex and birth date;
  3) name of the department—(if applicable), region and work phone number;
  4) payroll title, appointment and date of hire;
  5) the number of hours per day, days per week and total weekly hours that the employee works;
  6) indicate employee's status;
  7) list the employee's earnings (specify if earnings figure is monthly, weekly, daily or hourly); and
  8) list any other payments.
• The employee fills out the shaded section
• The employer or supervisor fills out the bottom section:
  1) comment on the circumstances of the injury by describing in detail how it occurred;
  2) provide information if you do not feel the injury is work related; explain and provide evidence;
  3) provide what steps you have taken or will take to prevent a similar injury/illness;
  4) complete signatures and date;
  5) make copies for your files .
• Do not keep your copy in the employee's personnel file: the report is confidential information and should be maintained in a separate file.

If the employee is taken off work due to the work-related injury:

• File the original doctor's order.
• Advise the employee regarding the Family and Medical Leave Act.
• Maintain weekly telephone contact with employee, EXCEPT in certain mental health cases where such contact could be misinterpreted.
• Stay in contact with the Workers' Compensation Adjuster assigned to manage the claim.
• Do not allow the employee to return to work without a medical release from a physician.
• Provide light duty and reasonable accommodation, if indicated, when the employee is able to return to work with restrictions.

If employee returns to work with medical restrictions:

• Thoroughly review the doctor's release and statement of medical restrictions.
• Provide light duty for 60 calendar days if medically indicated.

 

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