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Employee Relations

Areas of Support

Workers' Compensation Procedures for Supervisors

In compliance with Section 3760 of the California Labor Code, an employer must report every injury or occupational illness arising out of and in the course of employment. To comply with this code, all supervisors should complete the necessary forms and adhere to the following workers' compensation procedures.

  1. AUTHORIZATION FOR MEDICAL ATTENTION: If medical attention is necessary, the supervisor will complete the yellow card, stating that the supervisor is authorizing medical treatment at the Student Health Center or U.S. Healthworks. Or, in the event a personal physician has been pre-designated in writing, the employee may seek treatment with that physician.
  2. SUPERVISOR ACCIDENT INVESTIGATION REPORT - EH&S FORM 620: When an employee is injured on the job, the supervisor must complete a Supervisor's Accident Investigation Report (EH&S form 620) (.pdf). After completing Form 620, please fax a copy to Human Resources at (818) 677-7270. The original copy must be mailed to the Office of Human Resources within 24 hours of the report of injury/illness or you must call and report the injury to Human Resources. Failure to complete this form or to not report the injury can delay benefits to the employee, result in a monetary fine for CSUN, or both. A copy of Form 620 should also be sent to Environmental Health & Safety (mail code 8284).
  3. EMPLOYEE CLAIM FORM (DWC FORM 1): After the necessary medical attention has been received, the supervisor is required by law to provide the injured worker with an Employee's Claim for Workers' Compensation form (DWC-1) (.pdf) within one day of receiving notice of an injury which results in lost time beyond the date of injury or which results in medical treatment beyond first aid. Examples of first aid could include: minor scratches, cuts, burns, splinters etc.

    If the employee elects to file a workers' compensations claim, the employee will complete the top portion of this form and then immediately return the DWC-1 in person to Kari Dom in the Office of Human Resources, University Hall room 165. In the event the employee is off work and unable to return the form in person, the supervisor should immediately send the form to: Office of Human Resources, Attn: Kari Dom (mail drop 8229). The Office of Human Resources will complete the bottom portion of the claim form and advise the employee of the claims process.
  4. RETURN TO WORK: All lost time should be verified in writing by the treating physician. After seeking medical care, the physician will provide the employee with a supplemental report and complete the job activity analysis (if available). Copies of all reports are to be returned to Kari Dom in Human Resources.

    If the employee is released back to work with restrictions, hand carry the report and job activity analysis (if available) to Kari Dom, University Hall, Room 165. Meet with Kari and the employee to develop a Transitional Employment Plan, to allow the employee to work within his/her restrictions. The employee, supervisor, and Kari Dom sign this plan, with copies given to each.

If you have questions, please contact Kari Dom (kari.dom@csun.edu), Workers' Compensation Specialist, at Ext. 3351, Office of Human Resources, University Hall, Room 165, mail code 8229.