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Workers Compensation

workers Compensation

Reporting a Claim/Injury


When an injury/illness to an employee occurs while working, the injured employee has the right to file a workers’ compensation claim. The employee’s supervisor or School Administrative Assistant must be notified IMMEDIATELY no matter how slight the injury may be. Any delay in reporting a work related injury/illness, by either the employee or the employee’s supervisor, can impact the progress of the claim or medical treatment.


Types of Work Related Injuries/Illnesses


      1. Life threatening/serious injuries (e.g. excessive bleeding, broken bones, chest pain, unconsciousness). Call 911 or go to              the nearest ER. The employee’s work site must notify Human Resources immediately when a work incident requires                          transport by ambulance, ER visit or hospital admittance.


      2. Minor injuries/illnesses (e.g. minor bumps, scrapes) These minor incidents do not impact an employee’s ability to continue            working and require no medical treatment or care. 


      3. Injuries/illnesses beyond First Aid (e.g. back injuries, knee strains, exposure to hazardous substances). Employee will be               referred to a designated occupational medical facility for non-emergency medical care.


Workers' Compensation Required Forms


Required forms to be completed and/or provided to injured employee no later than one (1) working day from notification of injury:


          Workers' Compensation Packet Check List

The workers’ compensation check list must be used by school/department staff to ensure all necessary forms have been provided to the injured employee and completed as directed. This check list must be returned with all other items to HR.


      1. Employee Statement of Occupational Injury or Illness

Employee must complete this form describing the events surrounding their work related injury/illness. Employees choosing not seek to medical care or who do not wish to file a workers’ compensation claim must still complete this form. Employees must return this directly to their supervisor for submission to HR. 


      2. Supervisor's Report of Employee Injury

Supervisor completes this form in its entirety every time an occupational injury/illness is reported and submits it to HR. This form is required whether or not an employee wishes to seek medical care or file a workers’ compensation claim.


Complete/provide the following additional items ONLY IF (1) injured employee seeks medical treatment and/or (2) injured employee is filing a workers’ compensation claim:


      3. Covered Employee Notification of Rights

This document provides information to the injured worker regarding their rights in choosing medical care for their work- related injury or illness.  


      4. Notice of Potential Eligibility & Workers’ Compensation Claim Form DWC – 1

This form should only be provided to and completed by injured employees who seek medical treatment for their workers’ compensation injury or those wishing to file a claim. All items on this form must be filled out by hand. Employee must fill out the top portion marked “Employee” and the supervisor fills out bottom portion marked “Employer.” Supervisor must give employee a copy of the DWC – 1 form and forward the original to HR.


      5. Temporary Prescription ID Card

For an employee seeking medical treatment, this form must be completed by the supervisor and provided to the injured employee for use to obtain medication if prescribed by the workers’ compensation physician. This is only a temporary RX card to be used until a more formal card is issued to the employee by the claims examiner/Keenan. A list of approved retail pharmacies is included.


      6. List of Approved Medical Providers

If the injured employee does not have a pre-designated physician form on file with the HR Department, the employee must be treated by one of the covered medical providers listed here in order for their medical care to be covered under their workers’ compensation claim.


Returning to Work


The medical provider treating the employee’s work related injury/illness will issue the employee a Work Status Report after every visit. It is the employee’s responsibility to provide a copy of this report to the HR Department after each appointment. An employee cannot return to work unless they have been authorized to do so by either their supervisor or the HR Department.


If the treating physician releases an employee back to work with restrictions, the HR Department, along with employee’s supervisor, will determine whether or not an employee’s work restrictions can be accommodated and/or if a transitional or modified work assignment is available. The injured employee must remain off work until a decision has been made and the employee has been notified.



If you should have any questions concerning the necessary forms or procedures, please contact Yvette Mindeguia in the Human Resources Department by calling 650-877-8735 or via email at