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Workers' Compensation

Time of Hire Pamphlet

The district's insurance provider, Special District Risk Management Authority (SDRMA), has retained Company Nurse to provide a telephone-based nurse triage program for workers' compensation members and Sedgwick to administer workers' compensation claims. Sedgwick ensures that injured employees receive all applicable benefits in accordance with California Labor Code regulations. The CCSD provides all reasonable and necessary medical treatment to injured employees due to a work-related injury or illness. In the event of a work-related injury/illness, employees should immediately report an injury to his/her supervisor and complete a Workplace Injury Packet with his/her supervisor. The injured employee is responsible for providing Haley Dodson with an updated Employee Status Report after each medical appointment.

Declining First Aid Injury Treatment

In the event of a work-related injury/illness and the injured employee has declined medical treatment, the injured employee or their representative must complete the DWC-1 form within 24 hours of notification of work-related injury or illness.

The employee must do the following within 24 hours of employer knowledge of an employee injury or illness:

Company Nurse Injury Hotline Easy Reference Guide
  1. Call Company Nurse (877) 518-6711
  2. Complete the employee portion of the Department of Workers' Compensation DWC 1 Form.
  3. Complete the employee portion of the Declination of Medical Treatment Form (if the employee does not need or request medical treatment).
  4. Complete the employee portion of the Declination of Medical Treatment Incident Report Form (this form should be completed only if the employee does not need or request medical treatment).

The supervisor must do the following within 24 hours of employer knowledge of an employee injury or illness:

  1. Notify Haley Dodson immediately following work-related injury/illness.
  2. Complete the employer portion of the Department of Workers' Compensation DWC 1 Form.
  3. Complete the employer portion of the Declination of Medical Treatment Form.
  4. Complete the employer portion of the Declination of Medical Treatment Incident Report Form.
  5. Complete the Supervisor Incident Report Form.

Distribution of Forms:

  1. The employee keeps a copy of the DWC 1 Form and marks it "temporary receipt" until you receive the signed and dated copy from Haley Dodson. 
  2. The employee keeps a copy of the Declination of Medical Treatment Form and Declination of Medical Treatment Incident Report Form.
  3. The supervisor gives the completed forms to Haley Dodson immediately.
  4. Haley Dodson completes the OSHA 300 log and/or the initiation of standard safety investigation procedures in accordance with the Injury and Illness Prevention Program.
  5. Haley Dodson sends the Supervisor Incident Report Form with attachments to Sedgwick.

First Aid Injury with Treatment

In the event of a work-related injury/illness and the injured employee has requested medical treatment, follow all instructions prior to medical treatment. If the supervisor takes the employee to the medical facility, then the forms can be completed there. If there is an emergency call 911 first and then complete the forms as soon as possible after treatment. The injury employee or their representative must receive the DWC-1 Form within 24 hours of notification of work-related injury or illness.

The employee or their representative must do the following within 24 hours of employer knowledge of an employee injury or illness:

Company Nurse Injury Hotline Easy Reference Guide
  1. Call Company Nurse (877) 518-6711
  2. Complete the employee portion of the Department of Workers' Compensation Form (DWC-1).

The supervisor must do the following within 24 hours of employer knowledge of an employee injury or illness:

  1. Notify Haley Dodson immediately following work-related injury/illness.
  2. Complete the employer portion of the Department of Workers' Compensation DWC 1 Form.
  3. Complete the 5020 Form.
  4. Complete the Supervisor Incident Report Form.
  5. Provide the employee with their position description. 

Distribution of Forms:

  1. The employee keeps a copy of the DWC 1 Form and marks it "temporary receipt" until you receive the signed and dated copy from Haley Dodson.
  2. The supervisor gives the completed forms to Haley Dodson immediately.
  3. Haley Dodson completes the OSHA 300 log and/or the initiation of standard safety investigation procedures in accordance with the Injury and Illness Prevention Program.
  4. Haley Dodson sends the Supervisor Incident Report Form with attachments to Sedgwick.

Major Injury/Illness with Treatment

In the event of a work-related injury/illness and the injured employee has requested medical treatment, follow all instructions prior to medical treatment. If the supervisor takes the employee to the medical facility, then the forms can be completed there. If there is an emergency call 911 first and then complete the forms as soon as possible after treatment. The injury employee or their representative must receive the DWC-1 Form within 24 hours of notification of work-related injury or illness.

The employee or their representative must do the following within 24 hours of employer knowledge of an employee injury or illness:

Company Nurse Injury Hotline Easy Reference Guide
  1. Call Company Nurse (877) 518-6711
  2. Complete the employee portion of the Department of Workers' Compensation DWC 1 Form.

The supervisor must do the following within 24 hours of employer knowledge of an employee injury or illness:

  1. Notify Haley Dodson immediately following work-related injury/illness.
  2. Complete the employer portion of the Department of Workers' Compensation Form DWC 1.
  3. Complete the 5020 Form.
  4. Complete the Supervisor Incident Report Form.
  5. Provide the employee with their position description. 

Distribution of Forms:

  1. The employee keeps a copy of the DWC 1 Form and marks it "temporary receipt" until you receive the signed and dated copy from Haley Dodson.
  2. The supervisor gives the completed forms to Haley Dodson immediately.
  3. Haley Dodson completes the OSHA 300 log and/or the initiation of standard safety investigation procedures in accordance with the Injury and Illness Prevention Program.
  4. Haley Dodson sends the Supervisor Incident Report Form with attachments to Sedgwick.