Fillable EMPLOYEES REPORT OF OCCUPATIONAL INJURY OR ILLNESS (California State University, Los Angeles)

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EMPLOYEES REPORT OF OCCUPATIONAL INJURY OR ILLNESS (California State University, Los Angeles)

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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
L.A.
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
Name of the Injured:
Social Security Number:
Home Address (Number and Street, City, Zip):
Home Phone Number:
Birth Date:
Part B – EMPLOYEE STATUS
Classification:
Department:
Supervisor:
Hire Date:
per month or $
per hour
Sex:
Male
☐
Female
☐
Part C – INJURY/ILLNESS
Date:
Time:
a.m./p.m.
Date Employee Reported Injury:
Witnesses (Name and Telephone Numbers):
1.
3.
2.
4.
Where did injury/illness occur?
What were you doing when the injury/illness occurred?
How did the injury/illness occur?
Page 2 of 2 HRM/EEREPT (REV 02/2019)
Describe the nature of the injury/illness.
Was another person responsible?
☐
Yes
☐
No
If yes, explain.
Part D – MEDICAL TREATMENT
Where did employee receive treatment:
☐ CSULA Student Health Center
☐ Concentra Medical Group
☐
Hospital:
Name
Address
☐
Other:
Name
☐
Declined Medical Care
Part E – RETURN TO WORK
Did you lose at least one (1) full day of work after the date of injury/illness?
☐
Yes
☐
No
Did you return to work?
☐
Yes (returned to work on
) ☐
No
What type of work did you return to:
☐
Regular
☐
Modified
If you were unable to perform full duty, what type of temporary-modified work was made available to you?
Part F – ACCIDENT PREVENTION
Describe the workplace and conditions which may have contributed to the injury/illness and safety devices present :
What recommendations would you suggest which may correct the condition(s) and/or prevent future injuries/illnesses of this type?
Employee’s Signature:
Employee’s Name (print):
Working Title:
Extension:
Hire Date:
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EMPLOYEES REPORT OF OCCUPATIONAL INJURY OR ILLNESS (California State University, Los Angeles)

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Completed 22 July 2020

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