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

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SUPERVISORS 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
SUPERVISOR’S REPORT OF OCCUPATIONAL
INJURY OR ILLNESS
California law requires an employer to report within five days every injury or occupational illness which:
(1) results in time lost beyond the day of injury or
(2) requires medical treatment other than first aid.
This report is required by our Third Party Administrator (TPA) and the Department of Industrial Relations. Send ONE COPY to
Human Resources Management (HRM), Attn: Workers' Compensation Coordinator, Adm. 606 (Mail Code 8534-01). HRM will
prepare and submit the official report to the TPA. Make and retain a copy of the report for your file. FATAL or SERIOUS
injuries/illnesses must be reported IMMEDIATELY by telephone and on this form to Human Resources Management, who will
then report to the TPA and the Division of Industrial Safety as required by law. The Department of Public Safety is responsible
for making these reports to the Division of Industrial Safety when Human Resources Management is closed.
If you have any questions, please call extension 3657.
PLEASE REPORT ALL INJURIES (no matter how trivial) WITHIN ONE WORKING DAY TO YOUR EMPLOYER.
FILING THIS REPORT IS NOT AN ADMISSION OF LIABILITY
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:
Full-Time
☐
Part-Time
☐
Sex:
Male
☐
Female
☐
per month or $
per hour
Hours Worked:
Daily
Weekly
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 was the employee doing when injured?
Describe the nature of the injury/illness.
Page 2 of 2 HRM/EEREPT (REV 02/2019)
PLEASE ANSWER ALL QUESTIONS
Part C (Continued)
Describe the part(s) of the body injured.
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 the employee lose at least one (1) full day of work after the date of
injury/illness?
☐
Yes
☐
No
Did the employee 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?
Supervisors’s Signature:
Supervisor’s Name (print):
Position Title:
Extension:
Date:
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Completed 22 July 2020

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