When an employee sustains any work-related injury or illness, no matter how minor (bumps on the head, cuts, trip and falls, etc.) he/she must report it immediately to their Manager/Supervisor. If a Manager/Supervisor is unavailable, it is the responsibility of the employee to report the injury to the Fiscal Services Benefits Office.
To ensure prompt reporting of all non-life threatening injuries all employees must contact the Company Nurse Injury Hotline which provides District employees with 24/7 telephone access to Registered Nurses and medical professionals for prompt reporting of injuries. The Company Nurse Injury Hotline is (877) 518-6702. Company Nurse will refer the employee to an occupational medical facility to be evaluated. For all life threatening injuries, dial 911.
Following knowledge of the injury/illness and within 24-hours, the employee must be provided a Workers’ Compensation Claim Form (DWC 1) to be completed, signed and returned by the employee to the Fiscal Services Benefits Office. Completed claim forms must be received by Keenan within 5-days of the incident. It is essential that the Supervisor or employee advise Fiscal Services Benefits Office of any accident/injury as soon as he/she is aware. In the case of death or serious injury, contact the Fiscal Services Benefits Office immediately.
When an injury occurs, please provide the injured employee with the following documents:
- Workers’ Compensation Procedure
- Company Nurse Injury Hotline
- Workers’ Compensation Claim Form (DWC1) (Manager completes questions 12–14 and 17–19 and provides to employee. Employee completes questions 1-9 and returns to the Benefits office)
- Acknowledgement of Receipt of DWC1 (Employee completes and returns to the Benefits Office)
- PRIME Advantage MPM Complete Written Employee Notification
The Manager or Supervisor should complete the following and return to the Fiscal Services Benefits Office:
- Supervisor’s Report of Employee Incident or Injury
- Supervisor’s Supplemental Questionnaire
- Questionable Workers’ Compensation Injury Information (if applicable)
Contact Ron Owen, Senior Benefits Analyst, with any questions at firstname.lastname@example.org or (415) 457-8811, ext. 8159.
If you wish to designate a personal physician to treat you in the event of a workers’ compensation injury, please complete the Physician Pre-Designation form. This form must be signed by you AND your personal physician and submitted to Fiscal Services, Benefits Office, BEFORE an injury occurs, to be valid.
- Workers’ Compensation Pre-Designation Physician Memo
- Workers’ Compensation Pre-Designation Physician Form