SNAP : HOW TO: Report A Work-Related Injury, Accident, or Illness (for Supervisors)

HOW TO: Report A Work-Related Injury, Accident, or Illness (for Supervisors)

Summary: If your employee is injured or develops a job-related illness as a result of employment at UC Irvine, get medical attention for the employee and complete the required workers' compensation forms.

What you, the supervisor, should do How you should do it
1 Assist employee in obtaining medical authorization
Supervisor or Department Administrator should contact one of the following:
Workers' Compensation Unit, (949) 824-7008
One of the clinics noted below

In the event a Supervisor or Department Administrator is not available employee may go directly to the clinic.
2 If immediate medical attention is necessary, assist your employee
Treatment may be provided at one of the following clinics:
Newport Urgent Care, (949) 752-6300, (located off campus, map)
Occupational Health Clinic, (714) 456-8300, (at UCI Medical Center, map)
Occupational Services, (562) 933-0085, (located at Long Beach Memorial Hospital, map)
East Edinger Urgent Care, (714) 541-8464 (located off campus, map)

If your employee is unable to seek medical attention at one of these clinics, contact the Workers' Compensation Unit, at (949) 824-7008, for clinic referral.
3 Instruct the employee to submit an Incident Report

Report a work-related injury/ illness using one of the options below:
Online - complete Incident Report online in order to report any incident/ accident/ injury or illness arising out of and in the course of their employment.
Telephonic - report any incident/ accident/ injury or illness arising out of and in the course of their employment by calling 1-877-6UC-RPRT (1-877-682-7778) to submit an incident report. You will be connected to a call center for Sedgwick CMS, our Insurance Administrator. Note: the call center can accommodate employees speaking a language other than English.

If your employee is unable to complete either option, you, the supervisor, must complete it on their behalf.
4 Complete the Workers' Compensation Benefits Form (DWC-1) in 3 steps
Step One - As supervisor you have one working day to complete the following sections of the Workers' Compensation Claim Form (DWC-1) and hand it to the employee:

Employee section: Line 1 - employee name
Employer section:
line 11 - date when employee notified employer of incident
line 12 - the date on which the form was provided to the employee
line 16 - your signature
line 17 - your title
line 18 - your telephone number

Note: Lines 11 and 12 should be the same date or within one working day.

Step Two - Make one copy of the partially completed DWC-1 form for your records and give the original to the employee.

Step Three- The employee is not obligated to return the DWC-1 form; however, if they do, they are notifying their employer that they are pursuing workers' compensation benefits. If the employee does return the form, the supervisor must complete:
Employer section:
line 13 - date when employer received claim form from employee

Fax form to Workers' Compensation unit, (949) 824-9299.

Make a copy for your records and send the original, signed form to Workers' Compensation unit in Human Resources, 1000 Berkeley Place, Irvine, CA 92697-4600.
Your employee should only complete DWC-1 if they are filing a claim for workers' compensation benefits, including obtaining medical care from one of our doctors.

For more information refer to the Workers' Compensation menu.

Need an expert? Please contact the Workers' Compensation and Disability Management Unit at (949) 824-7008, Fax (949) 824-9299.

Notice: University policies, procedures and applicable collective bargaining agreements shall supersede information in this document or elsewhere on this site.