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
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 was the employee doing when injured?
Describe the nature of the injury/illness.