Skip to Local Navigation
Skip to Content
California State University, Long BeachCalifornia State University, Long Beach

Workers' Compensation

Forms

Contacts:

Cheryl Velasco
Workers' Compensation Manager
Phone: Phone:(562) 985-2366
Fax: (562) 985-7180

Workers' compensation provides benefits to employees who are injured or become ill during the course of or due to employment. The basis for the type and level of benefits available to an injured employee are the complex workers' compensation laws of the State of California.

The following information and guidelines will assist the campus community in understanding their rights and responsibilities under workers' compensation laws:

Responsibilities

Sedgwick CMS – provides all California State University (CSU) campuses with employee workers’ compensation claims administration services.

The Workers compensation coordinator – oversees and manages all workers' compensation claims made by CSULB employees.

CSULB Managers and Supervisors – assist in the management of workers' compensation claims filed by their employees. The CSULB Workers' Compensation Guide for Managers and Supervisors to assist managers and supervisors in meeting their responsibilities.

CSULB Employees and Volunteers – responsible for the timely reporting of work related injuries or illnesses and participating in their recovery process.

Benefits

Workers' compensation provides medical benefits if an employee experiences a work-related injury or illness. In addition, if you are medically determined unable to work because of the injury or illness, the CSU provides financial compensation to help replace lost salary or wages. The CSU Questions and Answers on Workers' Compensation and Industrial Disability Leave pamphlet provides an overview of these benefits.

Workers' Compensation Claim Form (Claim Form)

This Claim Form is a multiple page NCR form designed and distributed by the State of California. Employees must use an original form when submitting a claim. Claim forms are available from campus managers, supervisors, ASM’s, or from the workers’ compensation coordinator. Unless physically unable to do so, the employee must fill out the “Employee” section of the claim form. Anyone assisting an employee with completing the Claim Form is to attach a brief, signed statement explaining why the employee required assistance.

Please see our directions for completing the Workers' Compensation Claim Form.

Privacy Log Election Form

When an employee receives a Claim Form, he/she must also receive a Privacy Log Election Form. California law requires CSULB to maintain a log (Cal OSHA 300 log) of all work-related injuries and illnesses. However, due to privacy concerns for the injured employee the law provides recording of certain types of injuries on a separate privacy log. The privacy log contains the following:

  1. An injury or illness to an intimate body part or to the reproductive system.
  2. An injury or illness resulting from a sexual assault.
  3. A mental illness.
  4. A suspected or known infection of HIV, hepatitis, or tuberculosis.
  5. A needlestick injury or cut from a sharp object that is contaminated with blood or other potentially infectious material.

Any injured/ill employee may request the recording of his or her information be on the privacy log. The University does not release employee information recorded on the privacy log to other employees, former employees, or authorized employee representatives.

Predesignation of Personal Physician

California law allows employees to predesignate a personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) to treat them in the event of a work-related injury or illness if:

  1. your employer offers group health coverage;
  2. the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;
  3. prior to the injury your doctor agrees to treat you for work injuries or illnesses; and
  4. prior to the injury, you provided your employer the following in writing: (a) notice that you want your personal doctor to treat you for a work-related injury or illness, and (b) your personal doctor’s name and business address.

To predesignate a personal physician, you must submit a completed predesignation form to the Workers Compensation Coordinator prior to the date of injury or illness.

Back to top

Personal Chiropractor or Acupuncturist

You may be able to change the treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness if prior to the injury or illness you provided your employer written notice of your personal chiropractor’s or acupuncturist’s name and business address.

The claims administrator for the campus generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. You may complete and submit a Notice of Personal Chiropractor or Personal Acupuncturist form to the Workers Compensation Coordinator to document your request.

Coverage

CSULB provides workers' compensation coverage to employees while they are working in the course and scope of employment. Coverage begins on the first day of employment.

CSULB Volunteers are covered by workers' compensation when they are injured during the course of providing a service to CSULB. A CSULB Volunteer Identification form must be on file.

CSULB Students may be covered if they are participating in allied health or teaching clinical training programs in hospitals or with school districts.

The University does not typically extend workers' compensation coverage for any other clinical training programs or experience based learning programs including internships, practicums, fieldwork or service learning. Workers' compensation coverage for these students should be the responsibility of the third party (facility) who receives the benefit of the student's service as the facility has control over the risks of the work environment.

The University does not extend workers' compensation coverage to students participating in university-sponsored community service programs.

Disability Case Management Program (Return to Work)

Lost work time resulting from industrial or non-industrial injuries and illnesses is costly to the University and our employees. The CSULB Disability Case Management Program provides the structure to enable the campus to quickly and safely return employees to the workplace while reducing the costs associated with industrial and non-industrial leave programs.

The goal of the Disability Case Management Program is the safe, rapid return of injured or ill employees to transitional or regular employment. We believe that the needs of our employees and the University are best served when employees are able to maintain some form of medically appropriate employment from the time they become injured or ill until they are safely able to return to their regular employment duties. The program is designed to facilitate returning an employee to regular employment by providing appropriate temporary, alternate, or modified job duties for the injured or ill employee. The program is not intended to create new permanent positions within University colleges or departments.

Definition of Temporary Disability

A disability arising out of an injury or illness which prevents an employee from performing the full scope of his/her duties and responsibilities on a temporary period.

Definition of Permanent Disability

A disability arising out of an injury or illness which permanently prevents an employee from performing the full scope of his/her duties and responsibilities. A disability is considered to be permanent after the employee has reached maximum medical improvement or his/her condition has been stationary for a reasonable amount of time.