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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 | 20 <br />B) When employee declines 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 />• Should the employee decline medical treatment, the employee must <br />sign and date the Employee Request for Medical Treatment form <br />indicating, “I have declined the offer of professional medical <br />treatment at this time” <br />• File the Employee Request for Medical Treatment form along with <br />the Supervisor’s Report of Accident form in the departmental personnel <br />file <br />C) When employee seeks medical treatment at a later date after declining first request for: <br /> (Listed below is a detailed explanation of the use of each form. The number preceding the form <br />correlates to the form as it applies to each situation) <br />Form Process <br />A) Supervisors Report <br />of Accident (initial <br />report) <br /> <br />B1) Employee Request <br />for Medical Treatment <br />(copy of declined form) <br /> <br />B2) Employee Request <br />for Medical Treatment <br />(new) <br />If employee had originally declined medical treatment, but has now <br />decided to seek medical treatment for a work-related injury or illness, a <br />supervisor or manager must: <br />• Offer the employee immediate medical treatment. <br />• Provide a new original copy of the Employee Request for Medical <br />form <br />• Treatment form to the employee with the current date. <br />The employee must provide the request form to the treating physician <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: