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RMU Home » Programs » Workers' Compensation » Reporting an Industrial Injury

• Workers' Compensation
• Overview
• Reporting an Industrial Injury
• Resources for Injured Employees
• Resources for Workers' Compensation Liaisons and Disability Program Case Managers
• Resources for Supervisors and Managers
• Employees Essential Job Function/EF5
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Reporting an Industrial Injury

A nurse-staffed injury hotline is available to assist you to report industrial injuries and initiate the filing of a workers' compensation claim. The employee will still need to complete (and sign) a DWC-1 and return it to the supervisor, for scanning and e-mailing to the TPA.

A link to the nearly completed Form 5020 will be generated from the telephonic report. The TPA will contact the departmental workers' compensation liaison or disability program case manager to obtain additional information.

WE ENCOURAGE ALL DEPARTMENTS TO USE THIS SUSTAINABLE PROCESS.

In cases where it is not possible to report the injury through the hotline, forms may still be completed by hand and faxed to the TPA at 1-916-563-1919 or email to [email protected]

IF NOT A MEDICAL EMERGENCY, EMPLOYEE SHOULD CONTACT SUPERVISOR IMMEDIATELY AND
FOLLOW THE PROCESS BELOW.

1. Supervisor (with injured employee) immediately calls CarivaCare 24/7 to report injury and obtain treatment advice
2. CarivaCare gathers information over the phone and either recommends first aid or refers employee to appropriate medical treatment at a designated facility or pre-designated physician.
3. If medical treatment is beyond first aid, supervisor gives employee the DWC-1. Employee completes employee sections of the form and returns it to the supervisor. Supervisor completes employer sections and scans and fax to TPA.
4. Employee obtains appropriate medical care promptly at the designated facility or pre-designated physician as set forth in Labor Code section 4600(d) (1)-(d) (2).

Injured employees who initially receive only first aid treatment may call CarivaCare again if they need a referral or their symptoms worsen. CarivaCare is NOT a substitute for medical treatment.

• DESIGNATED PHYSICIAN AND MEDICAL FACILITY (PDF - 102kb)*: For non-emergency treatment, CarivaCare will direct the employee to go to an approved occupational health facility, unless they have pre-designated a physician prior to an injury. Even with a pre-designated provider, an employee may either go to that provider or an approved occupational health facility.

Forms you may need:

• DWC1 FORM (English (PDF - 104kb)* / Spanish (PDF - 104kb)*): Supervisor provides this form to employee within 24 hours of notice of injury requiring medical treatment beyond first aid or if physician certifies disability beyond the employees work shift at the time of the injury. ONLY THE EMPLOYEE MAY COMPLETE THE EMPLOYEE SECTION. Supervisor completes the employer section and submits to WCL/TPA.
• FIRST FILL PHARMACY FORM (English (PDF - 293kb)* / Spanish (PDF - 345kb)*): Give this notice to any pharmacy listed on the form to expedite the processing of your prescriptions.
• FORM 5020 (PDF - 533kb)*: State of California EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS. Supervisors only need to complete a hard copy of this form if they have NOT reported the injury to CarivaCare or entered the form online.
• SUPERVISOR'S INVESTIGATION OF EMPLOYEE INJURY (PDF - 286kb)*: This form must be completed by supervisor when obtaining information from the injured employee.
• WITNESS TO A JOB RELATED INJURY (PDF - 220kb)*: This form must be completed by any and all witness to a job related injury.
• WORK STATUS REPORT (PDF - 86kb)*: Employee should bring this form to each medical appointment. The medical provider must complete at every appointment, and employee must provide a copy to the supervisor/WCL.