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