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California State University, Long BeachCalifornia State University, Long Beach

Workers' Compensation Guide for Managers and Supervisors

Procedures for Work-Related Injuries and Illnesses

When University employees are injured or become ill as a result of work-related activities, they are entitled to Workers' Compensation benefits, provided the employee and supervisor comply with established procedures. The following detailed procedures are designed to assist supervisors and/or administrators when work-related injuries or illnesses occur. Failure to follow these procedures may delay or jeopardize the employees' benefits and add unnecessary costs to the University. If you have any questions after reviewing the procedures contact your Administrative Services Manager (ASM) or the Workers’ Compensation Coordinator at 52366.

When a Job Injury Occurs

  1. EMERGENCIES - For emergency assistance call 911

  2. If the injury does not require emergency assistance but does require medical attention do the following:

    1. Provide the employee with Employee's Claim for Workers' Compensation Benefits Form. You may pick up this form from the Workers’ Compensation Coordinato in person if you wish. Upon completion of the claim form provide the employee with the Temporary Receipt copy. Directions for the completion of this form may be found below.
    2. Provide the employee with an Authorization for Medical Treatment Form for the appropriate facility.

    3. Send or take the injured employee to one of the designated medical facilities. If the employee is incapable of driving him or herself to the medical facility for any reason the Appropriate Administrator shall arrange transportation. If necessary someone should accompany the injured worker to the medical facility. Employees injured during weekday hours should receive medical care at Memorial Occupational Medical Services of Long Beach, during times when Memorial Occupational Medical Services Health Care are closed, injured employees should receive medical care at Los Alamitos Medical Center Emergency Room.

    4. Prepare the Supervisors Review Form.

    5. Forward the completed Claim Form and Supervisors Review Form to Workers' Compensation Coordinator. The Workers' Compensation Coordinator must receive these forms within one working day (24 hours), fax to (562) 985-7180.

  3. If the employee feels the injury is not serious enough to warrant medical attention or a claim, it is recommended the supervisor record the incident:

    1. Prepare an Accident Investigation Report Form. A copy must be sent to the Workers Compensation Coordinator. Contact your ASM or DFO to determine where the department copy is to be maintained.

    2. Injuries for which the employee should be encouraged to seek medical evaluation include (but are not limited to):

      1. Orthopedic injuries (especially back/knee injuries)

      2. Cumulative trauma injuries (ex: carpal tunnel syndrome)

      3. Head injuries

      4. An injury resulting in loss of consciousness or ambulation

      5. Exposure to possible hazardous substances.

Directions for Completing Employee's Claim for Workers' Compensation Benefits

The Employee's Claim for Workers' Compensation Benefits form should be given to all employees who intend to seek medical care. If the employee is treated by a medical facility or they request a claim form, the Employee's Claim for Workers' Compensation Benefits form must be provided to the employee within 24 hours of the injury or request. If the employee is off campus, mail the form via FIrst Class mail with a cover letter. Provide a copy of the cover letter to Workers' Compensation Coordinator.

Employee Section

Review the following areas to ensure the employee has completed the form correctly:

  1. The date of injury, or the date the employee knew the injury or illness was job related.

  2. The place where the injury occurred, please ask the employee to indicate the exact location on campus.

  3. The description of the injury or illness; ask the employee to provide a complete description of the injury including the activity in which the employee was engaged in at the time of injury and what specific parts of the body are involved.

Do not complete the employee section for the employee unless he or she is unable to do so. The claim form is a legal document providing the injured employee an opportunity to state what has occurred.

Employer Section

Pay special attention to the following areas:

  1. The date the employer first knew of the injury that requires medical treatment or has loss t time*.

  2. Date you provided the employee a claim form**.

  3. Date employer received the completed claim form is the date the employee gave back the form.

  4. Signature of Employer Representative can be provided by a designated manager in the department, or by the Administrative Services Manager for your college or administrative unit.

* Date of knowledge: An employee may complain of an injury or illness to a supervisor or co-worker for some time before indicating to anyone the cause of the injury or illness was job related. The date the supervisor knew an injury was work related and required medical treatment or has lost time. (LC 5402)

** Date form was provided: The law states the employer must provide the claim form to the employee within one working day of the date of knowledge. In most cases this is 24 hours. If the employee notifies the supervisor on a Friday and neither employee is scheduled to work the weekend, then Monday would be the next working day. If the claim form is not provided to the employee within one working day, a memo must accompany the claim form when sending to the Workers Compensation Coordinator indicating the reason for delay. Be aware that failure to meet this regulation could result in fines against the University.

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When Your Employee Returns from the Physician

  1. The physician will give the employee a work status form which must be turned in to his/her supervisor. This form will indicate whether the employee can return to work, whether there are job modifications or restrictions, which must be made in order for the employee to return to work.


  3. If the work status report indicates the employee should not be working DO NOT permit your employee to resume work. The employee should be sent home. Do not permit the employee to take work home.

  4. If the work status report indicates the employee can return to work without limitations, allow the employee to resume working.

  5. If the work status report indicates the employee can return to work with limitations, determine the job modifications required to comply and refer to the campus Disability Case Management Program (Return to Work).

  6. Send or fax a copy of the work status report to the Workers’ Compensation Coordinator.. If the employee is unable to resume working and must lose time, notify the Workers Compensation Coordinator (ext. 52366) immediately!

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While Your Employee is Off Work

  1. Maintain contact with the employee so that you will always be aware of and involved with his or her health status and estimated return to work date.

  2. Notify the Workers' Compensation Coordinator of the employees anticipated return to work date. You must have a work status report releasing the employee to return to work from the appropriate treating physician before the employee can resume his or her job duties.