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San Joaquin County <br />Department of Public Works <br />County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e | 3 <br />Table of Contents <br />1. County of San Joaquin Department of Public Works Injury and Illness Prevention Program ................. 5 <br />1.1 Purpose.................................................................................................................................... 5 <br />1.2 Definitions ............................................................................................................................... 5 <br />1.3 Legal Authority ......................................................................................................................... 6 <br />1.4 Roles and Responsibilities ........................................................................................................ 6 <br />1.5 Polices...................................................................................................................................... 9 <br />1.6 Procedures ............................................................................................................................ 10 <br />1.7 Training .................................................................................................................................. 13 <br />1.8 Reporting and Recordkeeping ................................................................................................ 14 <br />1.9 Forms ..................................................................................................................................... 15 <br />1.10 Resources and Links ........................................................................................................... 15 <br />Appendix: .............................................................................................................................................. 18 <br />A. Injury and/or Illness Reporting and Claim Process .................................................................. 18 <br />FORM A - Supervisors Report of Accident Form ................................................................................. 22 <br />FORM B - Employee Request for Medical Treatment ......................................................................... 23 <br />FORM C - Workers’ Compensation Claim Form .................................................................................. 24 <br />FORM D - Employee Report of Injury or Illness ................................................................................... 28 <br />FORM E - Employee Request for Leave of Absence or Temporary Disability ....................................... 29 <br />FORM F- San Joaquin County Safety Condition Report ....................................................................... 31 <br />FORM G- San Joaquin County Incident Report ................................................................................... 32 <br />FORM H- San Joaquin Violence in the Workplace Incident Report ...................................................... 33 <br />Form I - San Joaquin County Vehicle Accident Form ........................................................................... 34 <br />B. Violence in the Workplace ......................................................................................................... 36 <br />1.1 Purpose.................................................................................................................................. 36 <br />1.2 Legal Authority ....................................................................................................................... 40 <br />1.3 Roles and Responsibilities ...................................................................................................... 40 <br />1.4 Polices.................................................................................................................................... 41 <br />1.5 Procedures ............................................................................................................................. 42 <br />1.6 Training .................................................................................................................................. 45 <br />1.7 Reporting and Recordkeeping ................................................................................................ 46