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Workers Compensation Check List

Workers' Compensation Poster
It must be posted where employees can read it. It must contain the name of the person to contact, emergency telephone numbers and information about the WC carrier.

Workers' Compensation Notice
The pamphlet entitled "Facts About Workers' Compensation" must be given to each new employee at the time of hire but not later than the end of the first pay period. That pamphlet describes the rights and obligations of employers and employees.
· Personal Physician Designation Form
. This enables an employee to designate, in advance of any injury, their
personal doctor to provide medical care for industrial injuries.
. The form must be provided on the first day of employment and annually thereafter by employers who offer employees two or more certified Health Care Organizations (HCOs).
. It must be provided only upon request for employers who do not offer
two or more certified HCOs.
. Then again, failure to provide "Facts About Workers' Compensation" as described above may result in the employer relinquishing the 30day medical control thereby enabling the injured worker. to seek medical attention without the employer's approval.
. Send a copy of the completed personal physician designation form to your insurance company. Keep the original in the employee's personnel file. Subsequently, place a copy into the employee's WC folder upon his/her filing of a claim.


[] Employee's Claim Form (DWC Form 1)
. It must be given to the employee upon your knowledge of a work
related injury or illness. The pamphlet entitled "Facts for Injured
Workers" must also be issued with the Claim form.
. Must be delivered personally or by first class mail within one working day after the employer knows of the injury or after receiving the employee's request for the form.
[] Employer's Report of Occupational Injury or Illness (Form 5020)
It must be completed ASAP and forwarded to your workers' compensation carrier. It is critical that the claim be reported promptly. A delay could result in the claim defaulting as being an admitted claim. Most WC carriers have a toll-free number for filing the Form 5020.
[] Emergency Medical Care
Determine, in advance, which physicians and hospitals injured workers should be sent to for emergency medical care. Identify the medical clinic; hospital and doctors to whom you will be referring injured employees. Include every conceivable specialty that may be needed, given the work environment, e.g., ophthalmologist, orthopedic, chiropractic, etc. Establish your protocol with each entity so that all matters are handled according to your instructions.
[] Emergency Numbers
Post names, addresses and phone numbers of ambulance services and your physicians and hospitals that should be used for emergency medical care.
[] First Aid
Identify trained personnel who will be responsible for first aid treatment. Maintain a record of first aid cases, including the employee's name, date of injury, one-time treatment provided and relevant surrounding circumstances and observations.
[] Employees' Emergency Information
Keep employees' emergency contact numbers up-to-date by reconfirming them semi-annually.
[] When an injury occurs:
. Offer necessary medical care.
. Notify employee's emergency contacts if necessary.
. Provide the employee with an "Employee's Claim Form for Workers'
Compensation Benefits" (DWC Form 1).
. File the DWC Form 1 with your insurance carrier immediately.
. File the "Employer's First Report of Occupational Injury or Illness" (DLSR 5020) with your insurance company within 5 days of knowledge of the injury.
. Report any serious injury or fatality to the nearest office of the California Division of Occupational Safety and Health (Cal/OSHA) within 8 hours.
. Correct any workplace hazards that may have led to the injury.
. Communicate with the injured employee as soon as possible to:
[] encourage his/her recovery and return to work
[] ask about the circumstances relating to the injury
[] ask if there where any witnesses
[] answer questions about workers' compensation benefits
[] ask for suggestions to prevent similar injuries in the future
[] assure the employee that you will personally see to it that
his/her claim is handled promptly .
[] TTD
Make sure the employee is receiving benefit payments in a timely manner and is being kept informed of his/her benefit status.
[] LC 132(a)
Don't discriminate against the injured worker or refuse to reinstate him/her. Contact Vic Mena. Consult with legal counsel.
[] Communicate
Maintain communication with the employee's immediate supervisor, department manager, health and safety officer, and human resources manager (this is you). However, do not divulge confidential medical information. 
[] Filling The Vacancy
Determine who will cover the injured employee's job duties during any absence related to the workplace injury. Do not fill the vacancy with a permanent replacement, at this time!
[] Benefits
Do not discontinue group health benefits without contacting Vic Mena.
[] Medical Records
Keep all medical records relating to the claim in a confidential WC file separate from the employee's regular personnel file.
[] Coordinate Leaves of Absence
If the employee is eligible for FMLA/CFRA, notify the employee immediately that the WC time off will count as family/medical leave, and provide him/her with any forms or documentation necessary. This will enable the employer to run these leaves concurrently.
[] ADA
If the employee becomes a QIW you may need to make a "reasonable
accommodation" under the Americans with Disabilities Act if he/she is
disabled as a result of the workplace injury. Refer to additional
information under the ADA.

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