| 1 |
Report the injury / illness to your supervisor |
- Inform your supervisor of your work-related injury or illness in one of the following ways:
- in person
- by telephone
- by email
- If your injury or illness developed gradually, such as tendonitis or hearing loss, report it as soon as you learn it was caused by your job. Immediate action will prevent delays in receiving benefits as well as the medical care you may need to avoid further injury.
If the University does not learn of your injury within 30 days, you could lose your right to receive workers' compensation benefits. |
| 2 |
If necessary, obtain immediate medical attention |
- Treatment may be provided at one of the following clinics by having your Supervisor or Department Administrator contact the clinic directly:
- Newport Urgent Care, Newport Beach
(949) 752-6300 (located off campus, map)
- Occupational Health Clinic, Orange
(714) 456-8300 (at UCI Medical Center, map)
- Kaiser Occupational Health Center
- Irvine, (949) 932-5899 (located off campus, map)
- Santa Ana, (714) 830-6660 (located off campus, map)
- Occupational Services, Long Beach
(562) 933-0085 (located at Long Beach Memorial Hospital, map)
- If you are unable to seek medical attention at one of these clinics, contact the Workers' Compensation Unit, at (949) 824-0500, for clinic referral.
In the event a Supervisor or Department Administrator is not available go directly to the clinic. |
| 3 |
Submit an Incident Report |
- • Report a work-related injury/ illness using one of the options below:
- Online - complete each section of the Incident Report online to report any incident/ accident/ injury or illness arising out of and in the course of your employment.
- Telephonic - report any incident/ accident/ injury or illness arising out of and in the course of your 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 you are unable to complete either option, your supervisor must complete it on your behalf. |
| 4 |
If only reporting an incident/ accident, keep the DWC-1 claim form for your records |
- Your supervisor must provide you with the Claim for Workers' Compensation Benefits form (DWC-1)
- If you are NOT pursuing a workers' compensation claim, keep the DWC-1 for your records.
If you decide at a later time to pursue a claim for workers' compensation benefits complete the claim form and return it to your supervisor. |
| 5 |
If initiating/ pursuing a claim, complete and sign the employee portion of the DWC-1 claim form |
- You can obtain the Claim for Workers' Compensation Benefits form (DWC-1) from your supervisor or from the Workers' Compensation unit in Human Resources.
- Complete the 'Employee' section, lines 1 through 9 of the DWC-1 form.
- Describe your injury or illness completely. Include every part of your body affected by the injury/ illness.
- Make a duplicate of the form for your records.
- Return the original form to your supervisor for further completion and your supervisor will forward to the Workers' Compensation Unit.
- By returning the form you are actually filing a claim. This notifies the employer that you, the employee, are pursuing workers' compensation benefits.
Only complete the DWC-1 if you are filing a claim for workers' compensation benefits, including obtaining medical care from one of our doctors. |
| 6 |
Notify EH&S of a work-incurred hospitalization or work-incurred death |
- If an employee is hospitalized for 24 hours or more, the department must immediately inform EH&S at (949) 824-6200 and provide:
- Time and date of accident;
- Employer's name, address and telephone number;
- Name and job title, or badge number of person reporting the accident;
- Address of site of accident or event;
- Name of person to contact at site of accident;
- Name and address of injured employee(s);
- Nature of injury;
- Location where injured employee(s) was (were) moved to;
- List and identity any other law enforcement agencies present at the site of accident; and
- Description of accident and whether the accident scene or instrumentality has been altered.
- Work-incurred deaths must be reported immediately to EH&S at (949) 824-6200, as required by California Division of Occupational Safety and Health.
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