Workplace 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 1-877-816-0611, or if the employee needs 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) (effective 9/1/2021)

Mitchell ScriptAdvisor First Fill - Temporary Prescription Card (effective 9/1/2021)

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

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

- WellComp Access to Medical Care Information: English and 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: [email protected] 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 employee contacts Company Nurse Hotline at 1-877-816-0611.

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.

COMPLETE INSTRUCTION & FORM PACKET: For your convenience, a packet with both the supervisor and employee required forms and information can be downloaded here.

Workers' Compensation Leave Update, Effective 7-1-22

As of July 1, 2022, any employee who misses time from work to attend a medical appointment to treat a

work-related injury will not be entitled to receive Temporary Disability or wage-loss benefits.

A ruling of the Sixth District Court of Appeals in Skelton v. WCAB found that Temporary Disability Indemnity

is intended to provide wage replacement only during a period where the employee is incapable of working.

For this reason, any employee who attends a medical appointment for a work-related injury during work

hours will be required to use sick-leave, vacation time or unpaid time off.

The exception to this rule would be the need for the employee to attend a Medical Legal Appointment

such as a Qualified Medical Exam or Agreed-upon Medical Exam.

Please contact [email protected] if you have any questions on this update.

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)

Workers' Compensation Fraud

Company Nurse Hotline Flyer

Concentra Urgent Care (First Care Provider)

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

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

Pre-Designation Form - Workers' Compensation

Pre-Designation Form: If you would like to be treated by your doctor in the event you have a workers' compensation claim, you and your doctor must complete and return the original signed form to the Benefits Coordinator in Business Services.

- YOUR DOCTOR MUST SIGN THIS FORM, agreeing to treat you as a workers' compensation patient prior to you getting injured. If you are injured at work without a pre-designated doctor on file, you will be treated by doctors at Concentra.