Attention - New Updates as of 01/13/15

Attention All Staff

Please review the following updates regarding workers' compensation:
  • Changes have been made to the Covered Employee Notification of Rights (under forms). Please discard the previous Covered Employee Notification of Rights forms, as that information is no longer valid.

  • If opting NOT to file a workers' compensation claim after sustaining an injury at work, the following items should be completed and submitted to the District Office: school incident report, Employee Questionnaire, and Supervisor's Report.

Workers' Compensation Required Forms

Required Forms to Complete and Submit to the District Office (Links at bottom)
  • Workers' Compensation Check List
  • Employee Questionnaire
  • Supervisor's Report of Employee Injury
  • DWC - 1 (Not Online)
  • 5020 (Not Online)
  • Clinic Evaluation Survey (Complete only if employee does not have a pre-designated physician)

Reporting a Claim/Injury

Claim Reporting

When an injury to an employee occurs while working, the injured employee has the right to file a workers’ compensation claim. This is a time sensitive process. The injured employee should report their injury to their supervisor as soon as possible. Once the supervisor is notified, they must provide the claim paperwork to the injured employee within one working day of notification. The completed paperwork must then be submitted to the District Office for submission to the insurer within 2 working days from the initial injury. Notify the District Office as soon as you are made aware of the injury. Be prepared to supply as much information as possible so that the claim may be submitted in a timely manner.

If an injured employee does not wish to file a workers’ compensation claim, the employee should still report their injury to their supervisor and complete an incident report for their work site and the Employee Questionnaire. Sites should also complete a Supervisor's Report for submission to the District Office.

Injured employees should submit ALL completed forms to their work site. The work sites will submit the completed workers’ compensation packet to the District Office.

Reporting Absences

How to Complete Absence Reporting

Enter "Industrial Accident" for the following:

  1. The initial day you leave work to seek medical treatment, if applicable.
  2. Any days indicated by a medical note that you must be COMPLETELY off from work.
  3. Scheduled surgery date, if applicable.
Enter "Personal Illness" for the following:
  1. Follow up medical appointments.
  2. Prescribed physical therapy or chiropractic appointments.
  3. Full day or partial day absences NOT supported by a medical note.

Returning to Work

The employee is not allowed to return to work without a written release from their treating physician. After the injured employee has been treated, they will be given a Work Status Report that should be submitted to their supervisor. All medically related notes and evaluations must be forwarded to the District Office. The injured employee must provide medical notes to their supervisor as soon as possible, but no later than the injured employee's next regularly scheduled work day.

After Initial Injury

A documented interactive meeting must take place between the employee and his/her supervisor prior to the employee resuming their duties after the initial injury. A copy of the summary of this interactive meeting should be forwarded to the District Office. This meeting is intended to verify the employee's ability to return to work with or without restrictions, based on the medical recommendations from the treating physician. A formal and documented interactive meeting should occur each time the injured employee submits a medical note with changes. If a new medical note indicates the same status, the employee's supervisor should briefly check in with the employee (no formal interactive meeting required) to ensure they are able to continue with the same working conditions.

After Released from Care/Permanent and Stationary Status

Another documented interactive meeting must take place between the employee and his/her supervisor prior to the employee returning after a permanent medical status has been reached. A copy of the summary of this interactive meeting should be forwarded to the District Office. This meeting is intended to verify the employee's ability to return to work with or without permanent restrictions, based on the medical release from the treating physician.

  • Interactive Meeting Template
    Employer (Administrative staff member) must complete this template to summarize interactive meetings with an injured employee. A copy must be submitted to the employee and the District Office.

Workers' Compensation Forms

Required Forms to Submit to the District Office:
  1. Workers' Compensation Check List
  2. Employee Questionnaire
  3. Supervisor's Report
  4. DWC-1 Form
  5. 5020 Form
  6. Clinic Evaluation Survey (Complete only if employee does not have a pre-designated physician)
  • Workers' Compensation Check List
    Cover page for submitting forms to the District Office. Employer must check off that each applicable item was covered with the injured employee. Requires printed name AND signature of employer and injured employee.
  • Kaiser Treatment Referral Form
    For treatment at Kasier On-The-Job. If employee does NOT have a pre-designated physician's form on file with Human Resources, then supervisor completes this form and gives it to the injured employee.
  • Covered Employee Notification of Rights (English)
    Reference material for injured employees.
  • Covered Employee Notification of Rights (Spanish)
    Reference material for injured employees.
  • WC Temporary Prescription Card
    Supervisor completes this form and distributes to injured employee for use if medication is prescribed by workers' compensation physician.
  • Employee Questionnaire
    Injured employee completes this form and returns it to their supervisor for submission to the District Office. ***NOTE*** - If injured at work, complete this form even if you do NOT wish to file a workers' compensation claim.
  • Clinic Evaluation Survey
    Injured employee must complete this survey if they have been treated by one of our medical providers.
  • Supervisor's Report of Employee Injury
    Supervisor completes this form in its entirety and submits it to the District Office.
  • DWC 1 - Example Only
    EXAMPLE ONLY - Actual form must be obtained at your work site.
  • 5020 - Example Only
    EXAMPLE ONLY - Actual form must be obtained at your work site. Signature at bottom must be employer's (supervisor or secretary), not employee's signature. Complete this form in its entirety to the best of your knowledge.