1. Workplace Injury Reporting for GSA Supervisors

2. An Employee is Hurt! What Now?
Employees who are injured on the job must immediately notify their supervisor about the time, place, type, and severity of the injury.

3. What if the Injury Requires Medical Treatment?
Ensure your injured employee receives immediate and appropriate medical attention. Direct the employee to one of the authorized primary care facilities, unless it is a life threatening injury.
If necessary, escort your
employee!

4. What is the Next Step?
For any injury resulting in lost time (beyond day of injury)
Give the employee an “Employee Claim for Workers’ Compensation Benefits (RM-135/DWC-1)” within 24 hours of knowledge of the injury.

5. Employee’s Claim for Workers’ Compensation Benefits (RM-135/DWC-1)

6. What Else Does the Supervisor Need to Give the Employee?
Also give the employee a “Physician’s Notice of Return to Work” form (RM-505)” to present to the treating physician for completion.

7. Physician’s Notice of Return to Work” (RM-505)

8. What if the Employee is Unavailable?
The Workers’ Compensation Claim form (RM-135) must be mailed (by certified post) or hand delivered to the employee within 24 hours

9. What’s Next?
Complete the “Employer’s Report of Occupational Injury or Illness” (RM-75)
Be sure to note date when the claim form was given to the employee.
If in doubt – fill it out!

10. Employer’s Report of Occupational Injury or Illness (RM-75)

11. To Whom do I Send the Employer’s Report?
Within 24 hours, send the Employer’s Report to GSA Personnel #1060 /FAX
Follow your departmental procedures to notify your management of the employee injury.

12. What Does the Supervisor Do in the Event of a Severe Injury?
Severe injuries are defined as: hospitalization for >24 hours; amputations; disfigurement; or death. They must be reported immediately to:
1) CorVel Risk Management at (866) or (805)
2) Cal/OSHA (805)

13. What if the Injury is Minor?
If the injury doesn’t require medical treatment (other than first aid)…
Document the injury. Complete Employer’s Report of Occupational Injury or Illness” (RM-75) and note “for reporting
purposes only.”
Forward to GSA Personnel/Safety #1060
If in doubt – fill it out!

14. Always Investigate Workplace Accidents & Near-Misses
Investigate as soon as possible & to prevent a reoccurrence - immediately correct any unsafe condition.
Complete the “Accident / Incident / Near- Miss Investigation Report” & forward a copy to GSA Personnel/Safety #1060.

15. Accident / Incident / Near-Miss Investigation Report

16. Security Incident Report Option
In the event that a third party report would be helpful, call Security at (805) to request an independent investigation.
The supervisor must still
conduct an their own
investigation.

17. Reporting Checklist…
Provide Workers’ Compensation claim form (RM- 135) to employee
If form is returned by employee forward to GSA/HR #1060
Complete Employer’s Report of Occupational Injury or Illness (RM75)
Ecopy Employer’s Report to Personnel & mail original #1060
Follow-up with Incident/Accident Investigation

18. Helpful Numbers CORVEL Risk Management
Phone: (805) or (866)
FAX: (805)
GSA Safety & Personnel
Phone: (805) or (805)
FAX: (805)
Workers Compensation Risk Management
Phone: (805)
FAX: (805)
Local State Workers’ Comp Office (805)
Cal/OSHA Ventura Office (805)
Security (805)

19. Reporting Forms
Employee’s Claim for Workers’ Compensation (RM-135/DWC-1)
Employer's First Report of Occupational Injury or Illness (RM-75)
Physicians Notice of Return to Work or Temporary Medical Restrictions (RM-505)
Accident / Incident / Near-Miss Investigation Report (CEORM-75I)

20. Helpful Websites
CA Dept of Industrial Relations – Workers’ Comp
Cal/OSHA
OSHA
VC Web Risk Management Workers Compensation & Disability
VC Web Risk Management Health & Safety