Workers' Compensation Program

All Los Rios employees – including all regular, temporary, student help, and some students in unpaid on-the-job training programs – may be covered by Workers’ Compensation. When a work-related injury occurs, follow the Campus Workers' Compensation Procedures.

Reporting Forms

After calling Company Nurse, Company Nurse will partially complete the Employee's Claim For Workers' Compensation Benefits (Form DWC-1) and the Employer's Report of Occupational Injury or Illness (Form 5020) and email/fax them to the campus and department. The supervisor then reviews the information, complete the forms, and forwards all three forms to the vice president of administration's office.

• Form DWC-1 – In the Employer section, fill in lines 10 to 13. Copy and give the original form to the employee within one working day of receiving knowledge of a work-related injury. When the employee returns the completed form (lines 1 to 9), the supervisor completes lines 14, 17, and 18. Note: To file a work comp claim and seek medical treatment, the employee must complete the top section of the DWC-1 and return to their supervisor. Employee must file a claim form in order to use Workers' Compensation as a reason for an absence.
• Form 5020 – Complete the missing information, check for accuracy, sign, and date.
• Supervisor's Report of Employee Injury Form – Complete the form, including the specific steps that have been taken to prevent similar accidents (for example, provided training, repairs/maintenance of facilities, and so on) and sign.

Information for Injured Employees

Los Rios has elected to self-fund workers' compensation benefits required by the California Workers' Compensation law. This means that medical bills and all other benefits are paid directly with district funds. Your workers' compensation rights are completely protected. Download a Guide to Workers' Compensation Benefits or continue reading for more information.

What to Do If You Are Injured at Work

Report all work-related injuries and/or illnesses to your supervisor and to Company Nurse at (888) 375-9780. If your supervisor is unavailable, then report your injury to your supervisor's superior.

For emergency situations, call Los Rios Police or 911. After the emergency situation has stabilized, call Company Nurse to report the injury.

What is Company Nurse?

Company Nurse is an injury management service that provides guidance for injured employees in obtaining the appropriate level of treatment. Company Nurse also initiates the reporting process.

• Company Nurse – Frequently Asked Questions (PDF)
• Company Nurse Training

File a Workers' Compensation Claim Form

Your supervisor will give you a claim form for workers' compensation benefits. You will need to provide a detail explanation of the incident that caused your injury. If you receive first aid treatment for very minor cuts, scratches, splinters, and so on – and no time is lost from work – then you do not have to complete a workers' compensation claim form.

Lost Time From Work

If you miss any time from work, then you must submit a doctor's authorization to your supervisor and attach a copy to your absence report. Absence without doctor's authorization cannot be charged to work-related injury leave. Please keep your supervisor informed on how long you will be off work or when you can return to temporary modified duty (restricted duty), as determined by your doctor

Get Medical Treatment

If you require treatment in addition to first aid, then you may go to any of the following designated medical facilities.

If you need treatment after the designated medical facilities have closed or for emergencies, then you may go to one of the designated hospitals. Once you are released from the hospital, you should obtain follow-up care from one of the designated medical facilities.

You may be treated by your own personal physician if you have a completed pre-designation of physician form on file with General Services (prior to the date of the injury).

Who Pays for Medical Treatment?

All necessary bills related to your work-incurred injury or illness will be paid by the district, if you are treated by one of the designated facilities. Charges incurred at any other facility may not be paid by the district. Examples of covered expenses include:

• Doctor and hospital bills
• X-rays
• Medication
• Crutches or other accommodations needed to help you recover

You should not be billed for any medical service.

Additional Resources

• Campus Workers' Compensation Procedures