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.
For treatment at Kaiser 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.
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.
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.