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Workers Compensation

Reporting a Work Related Illness or Injury

Notice to Employees: A safe working environment is our number one priority. However, should you become injured or ill as a result of your job with the District, we want you to receive medical treatment. The steps below should be followed when reporting a work related injury or illness:

  1. Report your injury to your immediate supervisor.  You will be given the Report of Injury packet. All forms must be completed and returned to Lupe Valdez at the District Office.
    1. Supervisor's Report of Work Related Injury or Illness
    2. Employee Report Injury
    3. Physician's Work  Status Report 
    4. Workers' Compensation Claim Form (DWC1) 
    5. SISC I Form 5020
  2. Obtain treatment. Unless you have a Pre-Designation of Personal Physician on file with the District prior to your illness or injury, you will be directed to report to one of the pre-authorized treatment centers for initial visits. You will be provided with a treatment authorization form to one of these locations:
    1. Click here to view the list of SISC I Medical Provider Network (MPN) medical facilities authorized to provide treatment to you.
  3. As stated above, unless you have a Pre-designation Form on file with the District prior to your illness or injury, you must be treated by a physician within the District's. Medical Provider Network Handbook
  4.  Work status.  After your visit, the physician will provide you with a work status report.  Please provide a copy to your supervisor and Lupe Valez at the District Office. If the physician determines you may return to work with restrictions, you will need approval from your Supervisor. 
  5. Supervisor's role. Your supervisor will complete a Supervisors Report of Employee of Work Related Injury or Illness Form when you report your claim. The Supervisor is responsible in notifying the Human Resources Department when they are unable to accommodate an employee due to the physicians work restrictions.   

For an emergency situation, call 911 or go directly to the nearest emergency room.

CAL/OSHA COVID-19 Prevention Program (CPP)

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