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Appendix: A. Injury and/or Illness Reporting and Claim Process Purpose Appendix A documents the process to reporting and process claims related to an incident, accident or illness that an employee has incurred during working hours. The following process must be followed for filing of any claim related to the injury, illness or accident. Any needed forms are available through Department of Public Works offices or online with the County of San Joaquin's Human Resources Division (www.segov.org/department/hr/risk/forms) The most common situations in reporting employee occupation injuries and illnesses are: A) When employee requests immediate medical treatment. B) When employee declines medical treatment. C) When employee seeks medical treatment at a later date after declining first request for treatment. An explanation of the most common situations and the names of the forms required to complete the reporting process are listed below: A) When employee requests immediate medical treatment: Form Process A) Supervisors Report Upon notification of an injury or illness, a supervisor or manager must of Accident complete a Supervisor's Report of Accident form.The form should: • Include a detailed description of the accident • Be completed within 24 hours of the accident or injury. B) Employee Request Upon notification of an injury or illness, a supervisor or manager must: for Medical Treatment • Offer the employee immediate medical treatment • Provide the original copy of the Employee Request for Medical Treatment form to the employee C) Employee's Claim The Employee's Claim for Workers'Compensation Benefits form must for Workers be completed if an injured employee: Compensation Benefits • Has notified the employer that medical treatment is or has been sought due to a work-related injury or illness and/or, • Is losing time due to a work-related injury or illness Employee must complete top portion of Employee's Claim for Workers' Compensation Benefits form with: • Date form provided to the employee • Complete description of the accident or injury • Body part(s) affected • Signature of the employee Employer must complete bottom portion of Employee's Claim for Workers' Compensation Benefits form and must: • Provide Employee's Claim for Workers'Compensation Benefits form San Joaquin County Department of Public Works County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 18