State of California
DEPARTMENT OF STATE
HOSPITALS REPORT OF
PATIENT WORKER
OCCUPATIONAL INJURY
OR ILLNESS
STATE COMPENSATION INSURANCE FUND
24-Hour Claims Reporting Center
Telephone: (888) 222-3211 Fax (800) 371-5905
THIS FORM IS NOT TO BE VIEWED OR COMPLETED BY THE PATIENT WORKER
PAGE 1 of 2
Any person who makes or causes to be made any
knowingly false or fraudulent material statement
or material representation for the purpose of
obtaining or denying workers' compensation
benefits or payments is guilty of a felony.
NOTICE: California law requires agencies to report within five days of knowledge every occupational injury or illness which
results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If a patient worker
subsequently dies as a result of a previously reported injury or illness, the agency must file within five days of knowledge
an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by
telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
1a. AGENCY CODE OR STATE FUND
POLICY NUMBER
Please do
not use this
Column
2. MAILING ADDRESS (Number and Street, City, Zip)
3. LOCATION, if different from Mailing Address (Number and Street, City, Zip)
4. NATURE OF BUSINESS; State Hospitals
6. TYPE OF AGENCY
PRIVATE X STATE
COUNTY
CITY
SCHOOL DIST.
OTHER GOVERNMENT - SPECIFY
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7. DATE OF INJURY / ONSET OF ILLNESS
(mm/dd/yy)
8. MILITARY TIME INJURY/ILLNESS
OCCURRED
9. MILITARY TIME PATIENT WORKER
BEGAN WORK
10. IF PATIENT WORKER DIED, DATE OF
DEATH (mm/dd/yy)
11. UNABLE TO WORK FOR AT LEAST ONE
FULL DAY AFTER
DATE OF INJURY?
12. DATE LAST WORKED (mm/dd/yy)
13. DATE RETURNED TO WORK N/A
(mm/dd/yy)
14. IF STILL OFF WORK
YES
NO
15. NUMBER OF DAYS AWAY FROM WORK
AS A RESULT OF THIS INJURY
16. SALARY BEING CONTINUED?
YES NO N/A
17. DATE OF AGENCY’S KNOWLEDGE/
NOTICE OF INJURY/ILLNESS (mm/dd/yy)
18. DATE PATIENT WORKER WAS
PROVIDED DWC 1
(mm/dd/yy)
19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning.
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address)
21. ON AGENCY’S PREMISES?
YES NO
21a. WAS ANOTHER PERSON
RESPONSIBLE?
YES
NO
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED,
e.g., Shipping department, machine shop.
22a. Serious Incident Report #
23. OTHER INDIVIDUALS INJURED OR ILL IN THIS EVENT?
YES NO
24. EQUIPMENT, MATERIALS AND CHEMICALS THE PATIENT WORKER WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., lawn mower, haircutting shear.
25. SPECIFIC ACTIVITY THE PATIENT WORKER WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., trimming hedges, mopping floors, loading boxes onto truck.
26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS,
e.g., Patient worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY.
27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip or Institution)
28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? NO YES If yes, then, NAME AND ADDRESS OF HOSPITAL
(Number, Street, City, Zip)
29. Patient worker treated in Emergency Room?
ATTENTION: This form contains information relating to patient worker health and must be used in a manner that protects the confidentiality of patient workers to the extent
possible while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.
Note: Shaded boxes indicate confidential patient worker information as listed in CCR Title 8 14300.35(b)(2)(E)2.*
P
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30a. PATIENT WORKER #
31. SOCIAL SECURITY NUMBER
32. DATE OF BIRTH (mm/dd/yy)
33. PATIENT WORKER ADDRESS (HOME OR INSTITUTION)
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
36. DATE PATIENT WORKER ASSIGNED TO
POSITION (mm/dd/yy)
37. PATIENT WORKER USUALLY WORKS
hours days total
_______ per day _______ per week _______ weekly hours
37a. ESTIMATE DISCHARGE DATE
38. GROSS WAGES/SALARY
$ ___________________ per __________________
Completed By (type or print)
Patient Worker Supervisor (type or print)
* Confidential information may be disclosed only to the patient worker, former patient worker, or their personal representative (CCR Title 8 14300.35), to others for the purpose of
processing a workers' compensation or other insurance claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the agency
(CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and federal workplace safety agencies.
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FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE PATIENT WORKER WITHIN ONE
WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT.
