What to Do If An Injury
Occurs at Work
UC Sacramento Center
Prepared and Developed by Erin Choi, UCOP Student Intern
Injury at Work:
Instructions on UCOP Webpage
• UCOP Human Resources:
– http://hrop.ucop.edu/
• Employee – Injury at Work:
– www.ucop.edu/humres/workers_compensa
tion/employee/injury.html
• Supervisor/Manager – Injury at Work:
– www.ucop.edu/humres/workers_compensa
tion/supervisor/injury.html
What to Do If an Injury Occurs at Work
(Employees)
If injured at work:
– Report incident to your supervisor immediately
– Promptly obtain proper medical care
If emergency care is needed:
– Go to nearest emergency room
– Report injury to your supervisor as soon as
possible
– For follow up care, go to UCOP’s Occupational
Health Center or your designated physician
UC Designated Occupational
Health Facility for the
UC Sacramento Center
• Occupational & Environmental Medicine
UC Davis Medical Center
Cypress Building
2221 Stockton Boulevard, Suite A
Sacramento, CA 95817
(530) 754-7635
Medical Treatment - Employee’s
Personal Care Physician
• Employee can designate personal care
physician
– Must have completed pre-designation form
– http://www.ucop.edu/humres/workers_compe
nsation/employee/pre_form.pdf
• Employee should discuss with personal
care physician
– Physician must agree to treat employee in
accordance with California Workers
Compensation Laws
What To Do If an Injury Occurs at Work
(Employees Continued)
•
If the treating physician certifies you for
disability - Provide your supervisor with
medical certification of:
– Any and all disability leave dates;
– Any and all future changes in disability
leave dates
•
It is your responsibility to keep your
supervisor informed
Injury at Work
Supervisors – Three Immediate Actions
Arrange medical care for the employee
– If employee has signed the pre-designated physician
form on file; the employee can go to their physician
– Or refer employee to the UCOP Occupational Health
Center (UC Davis Medical Center) and contact HR
Benefits Office
Complete Incident Report – Section 2
– Employee completes Section 1
– Treating physician completes Section 3
Complete Employer’s Report of Occupational
Injury/Illness Form (5020)
http://www.ucop.edu/humres/workers_compensation/edb_
prep/procedure_2.pdf
UCOP Incident Reports
• Approximately 45 Incident Reports
submitted every year
• Why complete an Incident Report?
– Documents the incident
– Differentiate first aid/minor injury incidents from
workers compensation-type injuries
– Helps to significantly reduce UC’s workers
compensation costs
– Human Resources & Department Safety Officer
opportunity to review/investigate all incidents
University of California
INCIDENT REPORT
Section #1
EMPLOYEE INFORMATION:
Employee Completes This Section
• Section 1 of
the Incident
Report
– Completed
by the
employee
Campus: ______________________________________ Last four digits of social security number: _______________
Name PRINT: _______________________________________________________________Sex _ Male _ Female
Home Address: __________________________________ City: __________________________Zip: ______________
Home Phone: ____________________________________ Work Phone:_____________________________________
Department: ______________________________ Job Title: _______________________________________________
Work Hours: ____________________________ Hours Worked per Week: ____________________________________
Employment Type _ full-time _ part-time _ regular _ temporary _ seasonal _student _ volunteer _ appointment
Do you have other employment? _ yes _ no If so, where ___________________________________________________
INCIDENT INFORMATION
Date of Incident _____________________
Time of Incident: ________________________
Address/Bldg, name & room # of incident: ____________________________________________________________
Zip Code __________________________
State all parts of body and type of injuries involve (e.g. bruised right elbow)
______________________________________________________________________________________________
______________________________________________________________________________________________
Describe how incident occurred:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Was incident reported? _ yes _ no If “yes” to whom? _____________________________________________________
Date reported: ________________________________
Were there witnesses? _ yes _ no _ unknown
Name of Witness #1 (First and Last): __________________________________________________________________
Witness #1 Phone Number: _________________________________________________________________________
Name of Witness #2 (First and Last): __________________________________________________________________
Witness #2 Phone Number: _________________________________________________________________________
Is this a new injury? _yes _no If “yes” indicate date, If “no”, please indicate date of original injury
_______________________________________________________________________________________________
INITIAL MEDICAL TREATMENT
Was treatment received for this injury?
_ No medical treatment- reporting only _ Declined treatment at this time _ Treatment was/will be provided
Treatment was provided by: _ Self _ Occupational Health _ Emergency Room _ Other (please specify below)
If treatment was provided, name and location of medical provider.
Name: ____________________________________________ Address________________________________________
Phone: _________________________________________
I, the injured employee, herein certify the information above is true and to best of my knowledge
Date: _______________________ Signature of Employee:____________________________________________________
Incident Report Form
Section #2
• Non-emergency situation:
– Supervisor completes
Section 2 first; then
– Incident Report given to
employee to complete
Section 1
• Incident Reports
– Handed/mailed to employee
within 1 day of knowledge of
on-the-job injury/illness
– If mailed – Use proof of
service mail delivery form
Section #2
SUPERVISOR COMPLETES THS SECTION:
Supervisor Name: ___________ ___email address_____________
Work Phone: ___________________________________
Describe how the employee was injured. _______________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Did employee lose time from work? _yes_ no _unknown If ‘yes’ First
day of lost time
Was the Employee paid for the full date of injury? _ yes _ no
Date Employee returned to Work._________________________
Was there equipment involved? _yes _ no If answered “yes” what was
the equipment
What action will be taken to prevent recurrence? ________________
_______________________________________________________
_______________________________________________________
Other Comments:_________________________________________
_______________________________________________________
_______________________________________________________
Date: ___________Signature:___________ Title:________________
Incident Report Form
Section #3
• Medical care
provider
– Completes
Section 3 of
the Incident
Report (If
medical care
is required)
Section #3
MEDICAL PROVIDER COMPLETES THIS SECTION:
____________________________________________________________________________________
Medical Provider - What treatment was provided for this injury (check one) _ First Aid _ Medical Treatment
Return To Work: Can Return immediately _yes _ no
If no, date employee can return to work __________________________ _Full duty _ Restricted work
Employee can return to work with these specific restrictions: ________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Estimated period of absence: _______________ to_________________ Next appointment:___________
Date: ______________ Signature: _______________________________ Title: ____________________
____________________________________________________________________________________
Note: If, initially, first aid is rendered but at a later date treatment beyond first aid is required, please
contact the Workers’ Compensation Department immediately and initiate the filing of a workers’
compensation claim. Seeking first aid treatment and completion of this report does not waive the
employee’s right to file a workers’ compensation claim and seek benefits in accordance with statutory
workers’ compensation laws. A physician who treats an injured employee is required to file a 5021
(“Doctor’s First Report of Injury”) with the claims administrator for every work illness or injury, even first aid
cases where there is no lost time from work.
Completed Incident Report
• Placed in employee’s workers
compensation file
• Copy to UCOP Benefits Office:
– Hand delivered; or
– Fax (510)217-6062
• Copy to Department Safety Officer:
– Investigation and recommend corrective
measures
– Prevent similar incidents in the future
Employee Loses Time from Work
(Supervisors)
• Contact Employee Dept. Benefits (EDB) Preparer
or Department Personnel Assistant (DPA) for:
– Family Medical Leave Act (FMLA) Procedures and
Eligibility Criteria
• Notify UCOP Return to Work/Vocational
Rehabilitation Program.
– Reduce Lost Workdays:
• Provide medically appropriate modified work during the
transitional stages of your employee’s medical recovery
– Call Roger Howland at (510) 987-0893 for:
• Assistance/consultation in designing Transitional/Modified work
– The day employee returns to work:
• Notify UCOP HR Benefits Office to prevent overpayment of
disability benefits.
Injuries
• Call 9-911 (Emergency)
• Call UCOP Benefit Services as soon as possible
to report the serious injury:
–
–
–
–
(510) 987-0123 – Customer Service Line
(510) 987-0819 – Anne Buckland
(510) 987-0816 – Leslie Lyons
(510) 987-0893 – Roger Howland
• Remove the equipment from service (If applicable)
• Tag the equipment for identification (If applicable)
• Contact Roger Howland at (510) 987-0893 to
initiate an inspection
• For additional assistance – Contact UCOP Benefit
Services Office