1. What to Do If An Injury Occurs at Work
For this month’s safety meeting we will discuss the UCOP procedures on what to do if an injury occurs at work and the requirements for completing an incident report.
Prepared and Developed by Erin Choi, UCOP Student Intern

2. Injury at Work: Instructions on UCOP Webpage
UCOP Human Resources:
Employee – Injury at Work:
Supervisor/Manager – Injury at Work:
If you are injured at work, the procedures and the required steps can be found on the UCOP webpage. There are specific instructions depending if you are the injured employee or if you are the supervisor/manager of the injured employee.

3. What to Do If an Injury Occurs at Work (Employees)
If injured at work:
Report incident to your supervisor immediately
Promptly obtain proper medical care
If emergency care is needed:
Go to nearest emergency room
Report injury to your supervisor as soon as possible
For follow up care, go to UCOP’s Occupational Health Center or your designated physician
If you are an employee and you are injured at work:
Immediately report the incident to your supervisor
If medical care is needed either:
- Go to one of UCOP’s designated occupational health centers; or
- To your own primary care physician – BUT ONLY IF YOU HAVE FILLED OUT A PRE-DESIGNATION FORM PRIOR TO YOUR INJURY
If the injury is such that emergency care is needed:
Go to the nearest emergency room
Report your injury to your supervisor as soon as possible
If follow-up care is needed, go to one of the UCOP’s designated occupational health centers or your designated primary care physician if you have completed the pre-designation form
UCOP HR will provide you an Employee Claim Form (DWC-1). THIS FORM MUST BE COMPLETED AND RETURNED TO HR IF YOU HAVE RECEIVED MEDICAL CARE

4. UCOP Designated Occupational Health Facilities
Concentra Medical Centers
384 Embarcadero West, Oakland (510)
Kaiser On-The-Job
235 W. MacArthur Boulevard, 3rd Floor, Oakland (510)
University of California Tang Center
2222 Bancroft Way, Berkeley (510)
Medical Treatment – UCOP Designated Occupational Health Facilities:
If you need to seek medical treatment, there are 3 UCOP Designated Occupational Health Facilities in the Oakland/Berkeley area:
CONTACT UCOP HR TO GET AUTHORIZATION PRIOR TO SEEKING TREATMENT
Concentra Medical Center (Embarcadero West);
Kaiser On-The-Job (West McArthur Blvd); and
UC Berkeley Tang Center

5. Medical Treatment - Employee’s Personal Care Physician
Employee can designate personal care physician
Must have completed pre-designation form
Employee should discuss with personal care physician
Physician must agree to treat employee in accordance with California Workers Compensation Laws
Medical Treatment – Employee’s Personal Physician:
Employees can designate their personal physician for medical treatment, but the employee must complete a pre-designation form prior to injury. You can get the form from your Department’s Personnel Staff or via the UCOP webpage at the link on the slide.
Employee Should Discuss with Their Personal Care Physician
Physician must also sign the Form and agree to treat employee in accordance with California Workers Compensation Laws

6. What To Do If an Injury Occurs at Work (Employees Continued)
If the treating physician certifies you for disability - Provide your supervisor with medical certification of:
Any and all disability leave dates;
Any and all future changes in disability leave dates
It is your responsibility to keep your supervisor informed
If the treating physician certifies you for disability, provide your supervisor with medical certification of:
Any and all disability leave dates;
Any and all future changes in disability leave dates
It is your responsibility to keep your supervisor informed:
It is important to keep your supervisor informed of leave dates.
Your supervisor will need copies of your treating physician's certificates stating the dates of your medical disability.
Your supervisor should also be informed of all future changes in those dates.
Failure to provide this information may delay your payments and/or affect your other insurance coverage.

7. Injury at Work Supervisors – Three Immediate Actions
Arrange medical care for the employee
If employee has signed the pre-designated physician form on file; the employee can go to their physician
Or refer employee to one of the UCOP Occupational Health Centers and contact HR Benefits Office
Complete Incident Report – Section 2
Employee completes Section 1
Treating physician completes Section 3
Complete Employer’s Report of Occupational Injury/Illness Form (5020)
If an employee is injured at work, there are three immediate actions which the supervisor must do:
1. Arrange for medical care for the employee:
If employee has a signed pre-designated physician form on file; they can go to their own physician; or
Refer the employee to the UCOP occupational health center and contact HR Benefits Office
2. Complete Section 2 of the incident report and give a copy to the employee to complete Section 1
3. Complete the Employer’s Report of Occupational Injury/Illness, the Form 5020 within 1 working day
By taking these actions, the supervisor will:
- Satisfy California State requirements
- Minimize the severity of the employee’s injury; and
- Prevent future injuries by maintaining a safe work environment.

8. UCOP Incident Reports
Approximately 45 Incident Reports submitted every year
Why complete an Incident Report?
Documents the incident
Differentiate first aid/minor injury incidents from workers compensation-type injuries
Helps to significantly reduce UC’s workers compensation costs
Human Resources & Department Safety Officer opportunity to review/investigate all incidents
Number of Incident Reports:
UCOP receives an average of 45 incident reports every year.
Why Complete An Incident Report?
- It is important for employees and supervisors to complete the incident report because the incident report would document the incident for future reference.
- Allows UCOP Human Resources staff to review and differentiate first aid/minor type injuries versus injuries which should formally be classified as a potential workers compensation claim
- This significantly reduces UC’s Workers Compensation costs
- Provides Human Resources and the UCOP Department Safety Officers the opportunity to review and investigate all incidents. This will result in possible corrective action to prevent future incidents and therefore prevent a similar event from occurring in the future.

9. University of California
INCIDENT REPORT
Section #1
EMPLOYEE INFORMATION:
Employee Completes This Section
Campus: ______________________________________ Last four digits of social security number: _______________
Name PRINT: _______________________________________________________________Sex _ Male _ Female
Home Address: __________________________________ City: __________________________Zip: ______________
Home Phone: ____________________________________ Work Phone:_____________________________________
Department: ______________________________ Job Title: _______________________________________________
Work Hours: ____________________________ Hours Worked per Week: ____________________________________
Employment Type _ full-time _ part-time _ regular _ temporary _ seasonal _student _ volunteer _ appointment
Do you have other employment? _ yes _ no If so, where ___________________________________________________
INCIDENT INFORMATION
Date of Incident _____________________ Time of Incident: ________________________
Address/Bldg, name & room # of incident: ____________________________________________________________
Zip Code __________________________
State all parts of body and type of injuries involve (e.g. bruised right elbow)
______________________________________________________________________________________________
Describe how incident occurred:
_______________________________________________________________________________________________
Was incident reported? _ yes _ no If “yes” to whom? _____________________________________________________
Date reported: ________________________________
Were there witnesses? _ yes _ no _ unknown
Name of Witness #1 (First and Last): __________________________________________________________________
Witness #1 Phone Number: _________________________________________________________________________
Name of Witness #2 (First and Last): __________________________________________________________________
Witness #2 Phone Number: _________________________________________________________________________
Is this a new injury? _yes _no If “yes” indicate date, If “no”, please indicate date of original injury
INITIAL MEDICAL TREATMENT
Was treatment received for this injury?
_ No medical treatment- reporting only _ Declined treatment at this time _ Treatment was/will be provided
Treatment was provided by: _ Self _ Occupational Health _ Emergency Room _ Other (please specify below)
If treatment was provided, name and location of medical provider.
Name: ____________________________________________ Address________________________________________
Phone: _________________________________________
I, the injured employee, herein certify the information above is true and to best of my knowledge
Date: _______________________ Signature of Employee:____________________________________________________
Section 1 of the Incident Report
Completed by the employee
Section 1 of the Incident Report Form – Section to be completed by the employee.

10. Incident Report Form Section #2
Non-emergency situation:
Supervisor completes Section 2 first; then
Incident Report given to employee to complete Section 1
Incident Reports
Handed/mailed to employee within 1 day of knowledge of on-the-job injury/illness
If mailed – Use proof of service mail delivery form
Section #2
SUPERVISOR COMPLETES THS SECTION:
Supervisor Name: ___________ ___ address_____________
Work Phone: ___________________________________
Describe how the employee was injured. _______________________
______________________________________________________________________________________________________________
_______________________________________________________
Did employee lose time from work? _yes_ no _unknown If ‘yes’ First day of lost time
Was the Employee paid for the full date of injury? _ yes _ no
Date Employee returned to Work._________________________
Was there equipment involved? _yes _ no If answered “yes” what was the equipment
What action will be taken to prevent recurrence? ________________
Other Comments:_________________________________________
Date: ___________Signature:___________ Title:________________
Section 2 of the Incident Report Form.
The supervisor should complete Section 2 first. The supervisor should then give the incident report form to the employee to complete Section 1.
The Incident Report should be handed or mailed to the employee within one working day of knowledge of an on-the-job illness or injury. If the Incident Report form must be mailed to the employee it should be sent with a Proof of Service – Mail Delivery form.

11. Incident Report Form Section #3
Medical care provider
Completes Section 3 of the Incident Report (If medical care is required)
Section #3
MEDICAL PROVIDER COMPLETES THIS SECTION:
____________________________________________________________________________________
Medical Provider - What treatment was provided for this injury (check one) _ First Aid _ Medical Treatment
Return To Work: Can Return immediately _yes _ no
If no, date employee can return to work __________________________ _Full duty _ Restricted work
Employee can return to work with these specific restrictions: ________________________________
Estimated period of absence: _______________ to_________________ Next appointment:___________
Date: ______________ Signature: _______________________________ Title: ____________________
Note: If, initially, first aid is rendered but at a later date treatment beyond first aid is required, please contact the Workers’ Compensation Department immediately and initiate the filing of a workers’ compensation claim. Seeking first aid treatment and completion of this report does not waive the employee’s right to file a workers’ compensation claim and seek benefits in accordance with statutory workers’ compensation laws. A physician who treats an injured employee is required to file a 5021 (“Doctor’s First Report of Injury”) with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work.
Sections 3 of the Incident Report Form.
If medical care is to be provided, the employee should bring the incident report form to the Medical Provider to complete Section 3.

12. Completed Incident Report
Placed in employee’s workers compensation file
Copy to UCOP Benefits Office:
Hand delivered; or
Fax (510)
Copy to Department Safety Officer:
Investigation and recommend corrective measures
Prevent similar incidents in the future
Completed Incident Report
After the Incident Report is completed, the supervisor should place a copy in the employee’s Workers Compensation file.
A copy must be either hand delivered or faxed to the UCOP Benefits Office at
Provide a copy of the incident report to your Department Safety Officer. The Department Safety Officer would then review and investigate the incident. This allows the Department Safety Officer to recommend corrective measures to prevent similar incidents from occurring in the future.

13. Employee Loses Time from Work (Supervisors)
Contact Employee Dept. Benefits (EDB) Preparer or Department Personnel Assistant (DPA) for:
Family Medical Leave Act (FMLA) Procedures and Eligibility Criteria
Notify UCOP Return to Work/Vocational Rehabilitation Program.
Reduce Lost Workdays:
Provide medically appropriate modified work during the transitional stages of your employee’s medical recovery
Call Roger Howland at (510) for:
Assistance/consultation in designing Transitional/Modified work
The day employee returns to work:
Notify UCOP HR Benefits Office to prevent overpayment of disability benefits.
For Supervisors – If an Employee Loses time from Work:
Contact your Employee Departmental Benefits (EDB) Preparer/Departmental Personnel Assistant (DPA) for Family Medical Leave Act Procedures and Eligibility criteria
Attempt to provide return to work or vocational rehabilitation
- Reduce Lost Workdays by providing medically appropriate modified work during the transitional stages of your employee’s medical recovery.
- Call Roger Howland at (510) for assistance and consultation in designing Transitional/Modified work.
- The day your employee returns to work, notify UCOP HR Benefits Office to prevent overpayment of disability benefits.
By taking these actions, the supervisor will:
- Avoid legal fines and penalties being assessed against their departments.
- Assure that their injured employee is getting compensation in a timely manner.
- Minimize financial loss to the employee, the department, and the University as a whole

14. Injuries Call 9-911 (Emergency)
Call UCOP Benefit Services as soon as possible to report the serious injury:
(510) – Customer Service Line
(510) – Anne Buckland
(510) – Leslie Lyons
(510) – Roger Howland
Remove the equipment from service (If applicable)
Tag the equipment for identification (If applicable)
Contact Roger Howland at (510) to initiate an inspection
For additional assistance – Contact UCOP Benefit Services Office
In the event of emergency situations:
Call 9-911
Call the UCOP Benefit Services Office ASAP to report the serious injury – The contact phone numbers are listed on the slide.
If there is equipment involved in the injury, remove the equipment from service and tag the equipment for identification. It is important not to dispose or throw away the equipment in question.
Contact Roger Howland, the Vocational Rehabilitation Specialist, to initiate an inspection.
If you need additional assistance, call the UCOP Benefit Services Office