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B) When employee declines 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 • Should the employee decline medical treatment,the employee must sign and date the Employee Request for Medical Treatment form indicating, "I have declined the offer of professional medical treatment at this time" • File the Employee Request for Medical Treatment form along with the Supervisor's Report of Accident form in the departmental personnel file C) When employee seeks medical treatment at a later date after declining first request for: (Listed below is a detailed explanation of the use of each form. The number preceding the form correlates to the form as it applies to each situation) Form Process A) Supervisors Report of Accident(initial report) 131) Employee Request for Medical Treatment (copy of declined form) 132) Employee Request If employee had originally declined medical treatment, but has now for Medical Treatment decided to seek medical treatment for a work-related injury or illness,a (new) supervisor or manager must: • Offer the employee immediate medical treatment. • Provide anew original copy of the Employee Request for Medical form • Treatment form to the employee with the current date. The employee must provide the request form to the treating physician 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: 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 20