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Required Forms

Workers' Compensation Forms

Workers' Compensation Forms iconWorkers' Compensation Formstitle

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.