Employee Injury Information

If You Are Hurt on the Job, You Should:

  1. Report the Injury To Your Supervisor. Report any workplace injury or illness to your supervisor immediately.  If your injury or illness developed gradually (like tendonitis or hearing loss), report it as soon as you learn it was caused by your job. Reporting promptly helps prevent problems and delays in receiving benefits, including medical care you may need to avoid further injury.  Click here for the accident reporting flow chart.   
  2. Get Medical Treatment.  For emergencies call 911 from a cell phone or campus phone.  Other treatment options are described here.
  3. Fill Out A Claim Form.  Your supervisor will give you a claim form (DWC-1) within one working day after learning about your injury or illness. You use it to request workers' compensation benefits. Fill out and sign the employee portion of the claim form. Describe your injury completely. Include every part of your body affected by the injury. Give the form to your supervisor, (you have now "filed" a claim). Someone from the CSU's third party claims administration will contact you to direct your medical treatment.
  4. Participate With The Accident Investigation. The cause of your injury or illness needs to be determined by a thorough investigation by your supervisor and Environmental Health and Safety. The purpose of this investigation is to identify and locate accident causes and not to place blame. Accident investigation can uncover hazardous equipment or materials and helps the supervisor make engineering or work practices changes.
  5. Keep All Medical Appointments. You are expected to keep medical and therapy appointments or promptly notify the medical facility and supervisor and/or Human Resources of schedule changes. After treatment by a doctor, clinic or hospital, you should report your medical status (as well as delivering the status slip, if possible) to your immediate supervisor or the Office of Human Resources. During convalescence, you may be asked to respond to inquiries from the supervisor, Human Resources or Claims Administration. You should maintain accurate records of visits to medical facilities and time away from the job to assist with wage adjustments. You are expected to provide medical status reports periodically or when requested by the supervisor, Human Resources or the claims administrator.

Call the Workers' Compensation Claim Coordinator at X3351 or visit the Human Resources website for additional information at:

Procedures for Supervisors:

Get Medical Treatment.  For emergencies call 911 from a campus phone or (818) 677-2111 from a cell phone.  Other treatment options for the injured employee can be found on the Workers' Compensation website.

The clinic used by the University is:

US HealthWorks Medical Group
9700 De Soto Avenue Chatsworth, CA 91311
Phone: (818) 882-8100
Fax: (818) 700-8255

Map & Directions

Supervisor's Accident Investigation Report for Employee Injury:

The supervisor completes this form [Form 620 (Rev 8-16)] for every reported employee incident or injury/illness occurring on-the job. It should be completed through a one-on-one discussion of the circumstances that caused the accident so that workplace conditions or work practices that contributed to the accident can be corrected. For guidance with completing the form, see the Supervisor's Accident Investigation Guide.

Worker's Compensation and Accident Report Forms: 

  1. State of California "Employee's Claim for Workers' Compensation Benefits"
    This form, DWC Form 1, must be given to the injured employee within 24 hours of the employer's knowledge of the injury/illness, according to state law. The form spells out the benefits an injured employee may be entitled to receive. To meet the time requirement, it may be necessary to mail the form to the injured employee. It is up to the injured employee to complete the form and return it to management, if medical treatment is necessary. Otherwise, it does not have to be returned.
  2. Personal Physician Designation Form
    If an employee pre-designates a treating physician, that physician has to have seen that employee within the last year and maintain some of the employee's medical records. This designated physician agrees to accept fees for services that are regulated by the Labor Code. The completed form is maintained at the Office of Human Resource Services (UN 180).  Access this form here.
  3. Status Slip (Doctor's Note)
    This is the note from the treating doctor, clinic or hospital reporting on the injured employee's medical condition, required treatment and return to work status. The university requires a release from the treating doctor whenever an injured employee returns to work following an injury. Copies of the doctor's note(s) are supposed to be sent to your supervisor and HR to verify time off for an injury on the job.