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Workers' Compensation

Workers' Compensation - Injury Reporting Claim Forms

Physician Pre-Designation 

Under Labor Code Section 4600, you may elect to seek treatment from a private physician or medical group, should you ever need to seek medical treatment under the Workers' Compensation system. Please note that, if you wish to exercise this right, you MUST obtain the specific designation forms and have them completed and on file PRIOR to an injury occurring and PRIOR to seeking treatment. 

The Statement of Employee's pre-designated Physician Form needs to be completed and signed by the physician you wish to seek treatment with. 

It is important that you, as the employee, take the time to ensure that this designation is kept up to date. Should you have any questions regarding the status of your Statement of Employee's pre-designated Physician Form, please contact Kerry Castillo.

Workers' Compensation - Fraud

Workers' Compensation Fraud and abuse cost the District money that could be used for other purposes such as textbooks, salaries, supplies, etc.  It is every District employee's responsibility to protect the District's assets by reporting suspected fraud.

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned.

If You Are Injured...

IF EMERGENCY CARE IS NEEDED CALL 911

The injured employee with their site supervisor or representative will call Company Nurse at (888) 375-0280 Immediately! 

The DWC-1 form, Supervisor's Incident Investigation Report and Employee Incident Investigation Report should be completed and forwarded immediately to the Risk Management Department.

The Supervisor's Incident Investigation Report and Employee Incident Investigation Report must be completed and sent with the DWC-1 form. 

If the employee is directed to seek medical attention, Company Nurse will direct the employee to an appropriate facility that is part of our Medical Provider Network (MPN).

If the employee requests to be seen by his/her own private doctor and that doctor is not a member of the MPN, then there must be a predesignated physician form on file in Human Resources for that employee. You can contact Kerry Castillo (909) 336-4121 at the District Office to see if one is on file.

If the doctor gives the employee any medical restrictions, it must be determined by Risk Management and the employee's supervisor whether or not the employee can return to his/her regular job with modified duties.

  • Our Group Code is:  SCSRM
  • A triage nurse will determine the employee's medical action plan.
  • Company Nurse will generate a Workers' Compensation Claim Form (DWC-1)
  • Whether or not the employee is directed to seek medical care, the DWC-1 form, Supervisor's Incident Investigation Report and Employee Incident Investigation Report must be completed. 

Cal OSHA Reporting Responsibilities

 

Contact:

Kerry Castillo
Risk Management Coordinator
(909) 336-4121

Information and Documents

A safe working environment is a high priority for Rim of the World School District.  However, should you become injured or ill, as a result of your job, we want to ensure you receive prompt and quality medical treatment.  Using the links provided below will provide you, and the appropriate site personnel with the information and documents needed if you are injured at work.

Forms

Links

 

EMPLOYERS REPORTING RESPONSIBILITIES TO CAL/OSHA PERTAINING TO ON-THE-JOB INJURIES AND ILLNESS

Incidents requiring reporting to the Division within 8 hours:

  • Fatal injury to an employee
  • Serious injury or illness to the employee. A serious injury or illness is defined as:
    • “any injury or illness occurring in a place of employment or in connection with any employment which requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation” and:
  • Loss of a member of the body (e.g., amputation)
  • Serious degree of permanent disfigurement (e.g., crushing or severe burn-type injuries)
  • Multiple worker injuries requiring hospitalization

Every employer shall report immediately by telephone or fax to the nearest District Office of the Division of Occupational Safety and Health (Cal/OSHA) any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment.

“Immediately” means as soon as practically possible but not longer than 8 hours after the employer knows or with diligent inquiry would have known of the death or serious injury or illness. If the employer can demonstrate that exigent circumstances exist, the time frame for the report may be made no longer than 24 hours after the incident.

Information required to be reported to the Division*:

  1. Time and date of the accident.
  2. Employer’s name, address, and telephone number.
  3. Name and job title, or badge number of person reporting the accident.
  4. Address of site of accident or event.
  5. Name of person to contact at the site of the accident.
  6. Name and address of injured employee(s).
  7. Nature of injury.
  8. The location where the injured employee(s) was (were) moved to.
  9. List and identity of other law enforcement agencies present at the site of the accident.
  10. Description of accident and whether the accident scene or instrumentality has been altered.

*Document the Time, Date, and Name of the person who received the report.

Cal OSHA San Bernardino Office

464 W. 4th Street, Suite 332

San Bernardino, CA 92401

Phone: (909) 383-4321

Fax: (909) 383-6789

Email: DOSHSB@dir.ca.gov