COMPLIANCE INFO_2024 UPDATED TPR

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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 | 19 Form Process within 24 hours of notification of request for medical treatment and/or lost time • Enter date employer first knew of injury, which is the day the employee requested medical treatment and/or lost time • If the employee is not readily available to provide the Employee’s Claim for Workers’ Compensation Benefits form, the supervisor or manager must: o Complete the employer portion o Make copy of Employee’s Claim for Workers’ Compensation Benefits form indicating “date mailed” o Mail Employee’s Claim for Workers’ Compensation Benefits form to employee o Retain copy of Employee’s Claim for Workers’ Compensation Benefits form with Supervisor’s Report of Accident and Employee Request for Medical Treatment forms D) Employer’s Report of Occupational Injury or Illness The Employer’s Report of Occupational Injury or Illness form must also be completed and forwarded to Risk Management with the Employee’s Claim for Workers’ Compensation Benefits form within 5 working days of employer’s knowledge date If on-line filing is available in your department, then a pre-authorized departmental user may file the Employer’s Report of Occupational Injury or Illness form electronically. A copy of the submitted form should then be forwarded to Risk Management. Should the employee fail to return the Employee’s Claim for Workers’ Compensation Benefits form within the employer’s timeline of 5 work days, do not delay submitting the Employer’s Report of Occupational Injury or Illness form. Forward the retained copy of Employee’s Claim for Workers’ Compensation Benefits form, which indicates “date mailed”, to Risk Management. E) Notice of Leave of Absence for Temporary Disability Indemnity Payment If the injured employee is off work more than three days due to an on- the-job injury, the employee’s supervisor or manager must provide Notice of Leave of Absence for Temporary Disability Indemnity Payment form to the injured employee. The Notice of Leave of Absence for Temporary Disability Indemnity Payment form provides the department with the employee’s decision regarding use of their accrued time and billing of their insurance premiums for the employee’s dependents. The employee will complete the form and return it to their department. The Notice of Leave of Absence for Temporary Disability Indemnity Payment form shall be forwarded to the County Human Resources Department. On completion of the forms, follow the established guidelines to forward the forms.