Teammate Handbook Cover

STEP 5. IF THE EMPLOYEE REQUIRES MEDICAL TREATMENT OF ANY KIND BY A PHYSICIAN, IS SEEN IN THE EMERGENCY ROOM, OR IS PLACED ON RESTRICTED WORK OR DAYS OFF STATUS BY A PHYSICIAN: • Give the injured employee the enclosed Employee Claim Form (DWC 1) as soon as possible but no later than 24 hours after the injury . You may hand deliver the form, email or send in overnight mail. When you receive the completed DWC 1 back from the employee, be sure to date stamp it, complete the bottom employer section and return a copy to the employee. Be sure to document the date, method and person who provided the claim form to the employee. If the employee does not return the form, you have fulfilled your obligation – but must document the date it was provided. • DELIVER OR SEND ORIGINAL DWC 1 to HR after you and the employee have completed it, for those who return the form. Do not delay sending in the form or notifying HR about the injury if you do not have the DWC 1 back from the employee. You may send an email to HR@morganhill.ca.gov to notify HR or send a copy of the forms if necessary. • Complete the enclosed City of Morgan Hill Incident Report (2-sided Form) . (This is not the DWC 1; it is a separate form used for 2 important reasons: (1) to provide early status information to HR and Payroll and (2) to provide information to the City’s Safety Committee). • Complete all necessary forms in this packet and return to the Human Resources Dept. • If necessary, follow-up with Concentra and tell them that you would like a work status report upon completion of the employee’s treatment. Request that the office call you as soon as possible with the employee’s work status, and that the clinic/doctor should provide the employee with a specific and clearly written work status/restrictions/instructions report. • Keep Human Resources and Payroll informed about any time loss. Make sure that the code for JOB INJURY (JI) is used on the employee’s timecard that indicates the exact hours the employee has lost time at work due to this injury (initial doctor’s visit should not be recorded on the timecard).

Helpful Phone Numbers

Concentra - Gilroy Concentra – San Jose

(408) 848-0444 (408) 477-8080 (408) 848-2000 (510) 794-2521

St. Louise Regional Hospital

OSHA

* A Personal Physician Designation Form is a form that is provided to employees who desire to select their own physician who will treat them in the event of a job injury. This form must be completed on file BEFORE an injury occurs. Having this form on file allows the employee to bypass going to the City’s Occupational Health Clinics. In the event that the employee is initially seen at the City’s Occupational health clinic and he or she has a Personal Physician Designation form on file, the employee can change treating physicians as soon as physically possible assuming the Pre-Designation form was on file prior to the injury.

FORMS CONTAINED IN THIS PACKET: 1.

DWC-1 – Black and White form – State of California – Employee’s Claim for Workers’ Compensation Benefits. 2. City of Morgan Hill Incident Report form

Updated 07/20