Manager/Supervisor Injury & Illness Forms
The Manager/Supervisor will notify the Workers’ Compensation Coordinator at 510-885-4227 within 8 hours of notification of an employee’s work injury/illness. In case of emergency, dial 911 from any campus phone to be connected to campus police. They will send an officer and, if needed, emergency medical personnel to assist you.
For other injuries/illnesses contact Workers’ Compensation at 510-885-4227 for authorization for the employee to be seen for First Aid, by Student Health, or medical treatment at St. Rose Hospital Occupational Health (in Concord, John Muir Hospital; in Oakland, the Concentra Occupational Health Clinic).
Within 24 hours of notification of a work injury/illness, the supervisor completes the Supervisor’s Injury & Illness Incident Report. Fax the form to Risk Management at 510-885-4908. Send the original in campus mail to Workers’ Compensation SA4901. The Supervisor must provide a copy of the Employees’ Injury & Illness form to the employee.
The Workers’ Compensation Coordinator and Environmental Health and Safety (EHS) will contact the supervisor to complete an Accident, Injury or Illness Initial Investigation Report