Guide to Reporting a Work Related Injury/Illness
During normal business hours & not out of the area:
Immediately notify your supervisor or the Workers' Compensation Coordinator (WCC) at (209) 664-6921 so you can get medical help right away. Don't delay. There are time limits. If medical treatment is needed, send employee to the following facilities.
NOTE: Your employer has the right to select the physician who will treat you for the first 30 days unless there is a Pre-designated physician form on file prior to the injury. You may be able to switch to a doctor of your choice after 30 days)
- WC Information & Instructions (PDF)
- Pre-designated* Physician Form (PDF)
English | Spanish
- Pre-designated* Chiropractor or Acupuncturist Form (PDF)
- English | Spanish
*Form must be on file with the Workers' Compensation Coordinator prior to date of injury or illness.
Not during normal business hours and/or out of area
- Go to the closest Emergency Room
Within 24 hours after an injury / Illness occurs:
- Supervisor to complete:
Supervisor's Report of Injury - Paper Form
Supervisor's Report of Injury - Electronic Form
- Have employee complete the employee section of the EMPLOYEE WORKERS' COMPENSATION CLAIM FORM (DWC-1) within one working day.
- Return both completed forms to Faculty Affairs/Human Resources within 24 hours of injury/illness. Please FAX: (209) 664-7182; email: firstname.lastname@example.org; or hand deliver to MSR340.
Stanislaus State University
Faculty Affairs/Human Resources Office
Telephone: (209) 667-3392
Workers' Compensation Coordinator (WCC)
Telephone: (209) 664-6921
Fax: (209) 664-7182
Workers' Compensation Administrator
Sedgwick Claims Management (CMS)
Claims Adjuster: Yvonne Rivera
P.O. Box 14629
Lexington, KY 40512
Division of Workers' Compensation Information and Assistance Officer
31 East Channel Street, Room 450
Stockton, CA 95202
Telephone: (209) 948-7980
- WC Claim Form (DWC1).pdf
- Supervisor's Report of Injury - Paper Form
- Supervisor's Report of Injury - Electronic Form
- WC Information & Instructions
- Guidebook for Injured Workers.pdf
- English: WC Pre-designation of Personal Physician.pdf or WC Pre-designation of Personal Chiropractor or Acupuncturist.pdf
- Spanish: WC Pre-designation of Personal Physician.pdf or WC Pre-designation of Personal Chiropractor or Acupuncturist
- WC New Hire Notice.pdf
- Cypress Care First Fill Form.pdf
Workers' Compensation Benefits
You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illness. An injury or illness can be caused by one event (such as hurting your back in a fall); by repeated exposures (such as hurting your wrist from doing the same motion over and over) or injury or illness developed gradually (like tendinitis or hearing loss). If your employer does not learn about your injury within 30 days, you could lose your right to receive workers' compensation benefits.
Any injury arising from your voluntary participation in any off-duty, recreational, social or athletic activity that is not part of your work-related duties is not compensable under the Workers' Compensation Program.
If You Get Hurt
Get Medical Care
If you need first aid, contact your supervisor. If emergency care is needed, call 911 for immediate help or go to an emergency room right away. Tell the medical staff that your injury or illness is job-related. Your employer will advise you where to go for medical treatment. If you pre-designated a personal physician before injury (refer to Pre-Designated Physician section below) you may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days.
Report Your Injury to Your Employer
Immediately notify your supervisor or the Workers' Compensation Coordinator (WCC) at (209) 664-6921 so you can get medical help right away. Don't delay. There are time limits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after an employee files a claim form, the employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for the alleged injury and shall continue to provide treatment until the date that liability for the claim is accepted or rejected.
If you pre-designated a personal physician, you may see that physician right after you are injured. A Pre-Designated Physician must be your personal physician or chiropractor who has regularly treated you and has your medical records on file and the physician agrees to be pre-designated. To pre-designate, completed the (English) Pre-Designated of Personal Physician Form (Spanish) Pre-Designated of Personal Physician Form or the (English) Pre-Designated of Personal Chiropractor or Acupuncturist Form (Spanish) Pre-Designated of Personal Chiropractor or Acupuncturist Form and return to the Workers' Compensation Coordinator (WCC), MSR340.
Information and Assistance:
Refer to Guide Book for Injured Workers for additional information.
False Claims and False Denials
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned.
What is Workers' Compensation?
Workers' Compensation is an employer-paid benefit program that provides compensation and medical benefits if you are injured or become ill due to a work-related condition. The California State University (CSU) program is administered by Sedgwick Claims Management Services.
What is covered by this benefit?
Any injury or illness is covered if it is caused by your job. This includes serious injuries as well as first aid type injuries. Under workers' compensation law, you will receive help if you are injured, no matter who was at fault. The main question is whether or not the injury or illness was caused by your job. Final determination of eligibility for benefits is made by Sedgwick Claims Management Services.
When does coverage begin?
There is no waiting period for coverage by workers' compensation. Coverage begins the first minute you are on the job and continues any time you are working. Payment for medical treatment begins immediately. There is a three-day waiting period before the disability income benefit payments begin.
What are the benefits?
The program will pay all approved medical and hospital bills associated with your work-related injury or illness. If you are disabled, you may be eligible for Industrial Disability Leave (IDL) payments, or you may choose Temporary Disability (TD) payments. Temporary Disability payments are equal to two-thirds of your salary up to a maximum set by law. If you cannot return to your usual occupation due to the injury or illness, you may be eligible for permanent disability benefits. In addition, you may be entitled to Vocational Rehabilitation (VR) benefits, if you are unable to return to your usual job duties. While you are enrolled in a VR plan, the benefits are paid by your employer.
In case of death, qualified surviving dependents are eligible to receive benefits as set by law.
What needs to be done when injured?
Immediately report the job-related injury/illness to your supervisor. You will receive an Employee Claim for Workers' Compensation Benefits on which you should describe your injury and how, when, and where it occurred. Return the completed form to your supervisor or Human Resources Office. The Human Resources Office will send a copy to Sedgwick Claims Management Services and submit a claim on your behalf. Sedgwick Claims Management Services will then get in touch with you to explain the benefits you will be receiving.
Your supervisor or Human Resources Office will arrange for authorized medical treatment and complete the necessary reports. You must furnish your supervisor or Human Resources Office with a doctor's written "return to work" release prior to resuming your duties. INSURE YOUR RIGHT TO BENEFITS BY IMMEDIATELY REPORTING EVERY WORK-RELATED INJURY OR ILLNESS.
What choices are there regarding medical treatment?
Emergency or After Hours
In an emergency, contact University Police at x3114 or dial 911 from a campus phone. University Police will dispatch emergency services to assess and/or transport the injured employee. For injuries after hours, dial 911.
Notify your supervisor immediately. It is important to report injuries as soon as possible in order to receive the best medical care possible.
Your work-related injury can be examined and treated by the designated workers' compensation facility unless you have a Pre-Designated Physician Form on file with the WCC, then you can visit the pre-designated physician of your choice. In accordance with the law, after 30 days from the date of injury, you may be treated by a physician of your choice or at a facility of your choice within a reasonable geographic area.
What are Industrial Disability Leave (IDL) benefits?
If you are a member of the California Public Employees' Retirement System (PERS), you may be eligible for IDL benefits in lieu of Temporary Disability (TD) benefits. IDL has a three-day waiting period before paid benefits begin. The waiting period is waived if you are hospitalized or off work more than 14 calendar days. For the first 22 work days of disability, IDL provides an amount equal to your net pay (full pay minus an amount equal to OASDI and withholding taxes based on your exemptions). If disability continues beyond the 22 work days, IDL provides two-thirds of your gross pay for the balance of 52 weeks. While you are receiving IDL, your normal retirement contributions and voluntary deductions continue. If you are disabled beyond the expiration of IDL benefits, you may be eligible to receive Temporary Disability (TD) benefits. All qualified medical bills will be paid whether you receive IDL or TD.
Who is eligible for Industrial Disability Leave (IDL) with supplementation?
If you are a member of PERS, you may be eligible to supplement IDL with accrued leave credits. Your credits must be sufficient to provide with IDL an amount to equal your regular salary.
What are Temporary Disability (TD) payments?
If a work-related injury or illness prevents you from working, you are eligible for TD payments. The amount of TD is generally two-thirds of your salary not to exceed the maximum as set by law. There is a three-day waiting period before paid benefits begin. This waiting period is waived if you are off work more than 14 calendar days or are hospitalized. TD stops when the treating physician released you to return to work or says your condition is stabilized (permanent and stationary).
What are Permanent Disability (PD) payments?
PD payments are different from TD payments and compensate you for any permanent disability you may suffer from an accepted workers' compensation claim. The amount you will receive depends on the extent of your disability and the workers' compensation law, regardless of whether or not you are able to return to your work.
When will disability income payments begin?
CSU employees are paid on a monthly basis. If you are eligible for IDL or supplementation to TD, you will remain on the normal monthly pay cycle.
If you are receiving TD without supplementation or PD payments, you will receive payments approximately every two weeks. The TD and PD payments will normally be sent directly to your home from Sedgwick Claims Management Services.
What happens to your job?
The law prohibits your employer from discharging or discriminating against you because of a workers' compensation injury/illness. If you believe you have been discriminated against because of your injury, you should discuss your rights with an Information and Assistance Officer or with an attorney.
When should you ask for assistance?
If you have questions about your claim, seek assistance immediately from either the Human Resources Office or Sedgwick Claims Management Services which is processing your claim. If you are dissatisfied with the information provided, you may contact an Information Assistance Officer with the California Division of Workers' Compensation or an attorney.