Workers' Compensation Forms

Forms to be completed after an occupational injury or illness occurs:

• Incident/Injury Report (to be completed by the campus sheriff)

• Referral for Treatment of Occupational Injury or Illness Forms Updated Form (to be presented at the treatment facility)

• Workers' Compensation Claim Form (DWC-1) (to be completed by the injured employee and the Focal Point or Supervisor)
• Employer's Report of Occupational Injury or Illness Form (5020) (to be completed by the Focal Point)

• Supervisor's Report of Employee Injury or Illness Form (to be completed by the supervisor)

Should be completed before an injury occurs:

• Statement of Employee's Pre-Designated Physician and Employee Consent Form (to be completed by employees before an industrial accident occurs)

last updated 7/21/2010

lam