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

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.

SUMMARY OF POLICY

• When an accident or injury occurs on the job or at the job site, the incident must be reported to the Regional Office 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!
• Any time lost on the day of injury is paid as administrative leave.
• A Workers' Compensation Employee's Claim Form must be provided to the employee and a UCD Employer's Report of Occupational Injury or Illness form http://safetyservices.ucdavis.edu/workers-compensation/Forms/Report.doc 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 http://safetyservices.ucdavis.edu/workers-compensation/Forms/Report.doc (form WCER 1/94) 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 the University in violation of State Law and make it subject to monetary penalties. If you need assistance in completing this form, please call the Regional Office.
• 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.
• Records regarding first aid injuries do not have to be reported to the Regional Office.

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. Fax a copy of the Employee's Claim Form to the Regional Office along with the UCD Employer's Report of Occupational Injury or Illness http://safetyservices.ucdavis.edu/workers-compensation/Forms/Report.doc

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

If the supervisor receives the completed Employee's Claim Form back from the employee , the supervisor or administrative staff should fax the form to the Regional Office immediately. After that:

• Make a copy for your file.
• Send the Employer's copy and Adjusting Agency's copy to the Regional Office.
• Give Employee's copy to the employee in person or send via first class mail.

Form 2: UCD Employer's Report of Occupational Injury or Illness (form WCER 1/94) Instructions for completing Form 2:

•  The form must be typed and faxed to the Regional Office within one working day of when the employer learned of the injury or illness. The original form should be sent by mail to the Regional Office.
• 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—DANR, 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 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) obtain County Director's signature and date;
  5) make copies for your files and send all forms to the Regional Office.
• Do not keep your copy in the employee's personnel file: the report is confidential University information and should be maintained in a separate file.

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

• Provide original doctor's order to the Davis Campus Workers' Compensation Unit. Send a copy to the Regional Office and keep a copy for your files.
• Advise the employee regarding the Family and Medical Leave Act (FMLA information is available from the Regional Office).
• 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 Analyst assigned to manage the claim.
• Communicate with the Regional Office to verify appropriate accounting for the period of absence.
• 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 a copy of the medical release to the Regional Office.
• Provide light duty for 60 calendar days if medically indicated.

REFERENCE/WEBSITE LINKS

UC Davis Risk Management Workers' Compensation Desk Reference
http://safetyservices.ucdavis.edu/worker-compensation

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