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Human Resources Division

Manager/Supervisor Responsibility

Injured Worker Requests Immediate Medical Treatment

Labor Code 5401
Within one (1) working day of receiving notice or knowledge of injury/illness, which results in lost time beyond the date of injury or which results in medical treatment, the Manager/Supervisor shall provide, personally or by first class mail, a claim form and a notice of potential eligibility for benefits to the injured worker.

Forms required:

  1. Supervisor's Report of Accident, S&T 202 - NCR Form
  2. Employee Request for Medical Treatment, S&T 201 - NCR Form
  3. Employee’s Claim for Workers’ Compensation Benefits, DWC 1 - NCR Form
  4. Employer’s Report of Occupational Injury or Illness, 5020 - NCR Form
  5. Notice of Leave of Absence for Temporary Disability Indemnity Payment, Form 29 - E-From
  6. Request for Leave of Absence, RLOA - E-Form

Step 1:
The “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form must be provided to the injured worker within 24 hours. The injured worker must complete the top portion of the form:

  1. Date form provided to the injured worker
  2. Complete description of the accident or injury
  3. Body part/parts affected
  4. Signature of injured worker

Step 2:
The Employer must complete bottom portion of “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form and must: 

  1. Enter date employer first knew of injury, which is the day the injured worker requested medical treatment and/or lost time.
  2. If the injured worker is not readily available to provide the “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form, the Manager or Supervisor must:
    1. Complete the employer portion
    2. Make a copy of “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form indicating “date mailed”
    3. Mail “Employee’s Claim for Workers’ Compensation Benefit” (DWC1) form to injured worker, preferably certified mail
    4. Retain a copy of “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form with “Supervisor’s Report of Accident” (S&T 202) and “Employee Request for Medical Treatment” (S&T 201) forms

     

Step 3:
The “Employer’s Report of Occupational Injury/Illness” (5020) form must also be completed and forwarded to Risk Management with the “Employee’s Claim for Workers’ Compensation Benefits” (DWC1) form within 5 working days of employer’s knowledge date.

Step 4:
Worker’s Compensation Leave runs concurrently with Family Medical Leave Act (FMLA). For information on FMLA, see “Request for Leave of Absence form. (RLOA)

Step 5:
San Joaquin County’s Third Party Administrator (TPA), approves and authorizes worker’s compensation benefits. The TPA will have a period of time in which to accept, deny or delay a claim. This period of time is the “determination period”. The injured worker may elect to use their leave accruals during this period. The injured worker must complete a “Notice of Leave of Absence for Temporary Disability Indemnity Payment” (Form 29). If the injured worker is not available to complete this form, please mail to the injured worker for completion.

Step 6:
It is the injured worker’s responsibility to provide Manager/Supervisor any and all medical documentation for the workers’ compensation claim. Documents should include and are not limited to doctor’s first reports, work status reports, leave from work and work restriction notes. Provide Risk Management a copy of all documents received. Failure to submit doctor’s note may cause delay in Temporary Disability (TD) benefits to the injured worker.

Step 7:
Forward original forms (Forms 1-6 above) to Risk Management. If DWC1 was mailed to injured worker, submit copy indicating “date mailed” along with original documents. Do not delay submitting forms pending receipt of the original DWC1. The Employer has been placed on notice of an injury/illness. When the DWC1 is received from the injured worker, forward the form to Risk Management. Temporary Disability Indemnity Payments will begin when the workers’ compensation claim is approved by the TPA. Risk Management will coordinate the disbursement of the Temporary Disability Indemnity Payments. Amounts are based on the employee’s average weekly wage. Please note that claims which involve lost time from work require a three day waiting period before the start of Temporary Disability Indemnity Payments. If an injured worker is off work more than 7 days or requires immediate hospitalization this waiting period will be waived. 

Temporary Disability Indemnity Payments (TDI)