Manhattan Beach Unified School District

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Injury Reporting

 

A school district, being a dynamic environment, sometimes experiences accidents to employees. Should you experience a work related injury, please contact your supervisor immediately to fill out the appropriate forms. 

 

Employee's instructions in the event of a workplace injury: 

  • Employee should immediately contact Company Nurse Hotline at 1-888-770-0929, or if the employee is in need of immediate medical treatment, call 911 
  • Employee receives and completes the following information and forms:

**Receipt of Workers’ Compensation Information form 

**Workers’ Compensation Injury Questionnaire form  

**DWC-1 Claim Form (Employee section numbers 1 thru 9 only) 

   Cypress Care First Fill Flyer 

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish

 

**Employee must have contacted the Company Nurse Hotline and completed these 3-forms to initiate a claim. Please return all completed forms to your immediate supervisor, and/or send to Carol Gerken in the MBUSD Business Services office (EMAIL: cgerken@mbusd.org  or FAX: 310-303-3823)

 

Supervisor's instructions in the event of a workplace injury:  

  • Supervisor must provide employee with the required forms and informational pamphlets noted above as soon as they are aware of the injury.   
  • Please ensure the employee has contacted the Company Nurse Hotline at 1-888-770-0929. 
  • Supervisor must complete and return the Supervisor Report of Injury form to the MBUSD Business Service office along with the employee's required forms noted above.  For your convenience, a packet with both the supervisor and employee required forms and information can be downloaded here.
 

MANDATORY WORKPLACE WORKERS' COMPENSATION POSTERS/FLYERS:  Please post the following on all staff information bulletin boards or the like:

 

Notice to Employees--Injuries caused by Work (CA DIR):  Post in English and Spanish 

Workers' Compensation Fraud:  Post in English and Spanish

Company Nurse Hotline Flyer

Providence Urgent Care (First Care Provider) Flyer 

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish