Page 1 of 2 HRM/EEREPT (REV 02/2019
HUMAN RESOURCES MANAGEMENT
EMPLOYEE’S REPORT OF OCCUPATIONAL
INJURY OR ILLNESS
1. Notify your immediate supervisor as soon as possible of any injury/illness sustained during the course of your work with Cal State
2. Obtain medical from
Cal State L.A. Student Health Center; or
Concentra Medical Group or
Your personal physician
o Authorized only if you have submitted a Designation of Physician form to Human Resources Management
(HRM) before your date of Injury.
3. Within one working day, complete and return to HRM and provide a copy to your immediate supervisor:
Employee's Report of Occupational Injury/Illness
4. Continue with medical treatment as prescribed by the treating medical provider. After each medical visit, submit a copy of your
medical status documents to:
Your immediate supervisor, and
Human Resources Management
Upon receipt of the appropriate forms, Human Resources Management will coordinate the claim processing with the University's
insurance provider, the employing department, the medical provider and the employee. Should you require further assistance with this
form, please contact your workers' compensation coordinator at extension 3657.
Part A – PERSONAL INFORMATION
Home Address (Number and Street, City, Zip):
Part B – EMPLOYEE STATUS
Part C – INJURY/ILLNESS
Date Employee Reported Injury:
Witnesses (Name and Telephone Numbers):
Where did injury/illness occur?
What were you doing when the injury/illness occurred?
How did the injury/illness occur?