Workplace Injuries Information & Forms

• Employee's Guide to Workers' Compensation(opens in new window)
• Injuries on the Job Poster (opens in new window)
• Procedures for Workplace Injuries or Illness(opens in new window)
• Workers' Compensation Claim Form (DWC 1)(opens in new window)
• Work-Related Injury and Illness Incident Report (OSHA 301)(opens in new window)
• Work Related Injury and Illness - Pre-designation of Personal Physician, Chiropractor or Acupuncturist (for Work-Related Injury or Illness)(opens in new window)

• If the Injury requires emergency assistance, call 9 - 1 - 1.
• In serious illness/injury*, the employee should be transported to the nearest medical facility.
• In minor injury/illness, the injured workers should obtain medical care at the appropriate Designated Medical Facility.
• Leave the accident site undisturbed until Environmental Health & Safety (EHS) has had a chance to inspect it.
• Immediately report the injury/illness to the Employee Leaves and Workers' Compensation Unit, 530-898-4670.
• Immediately complete the Work-Related Injury and Illness Incident Report (OSHA 301). The employee must be given the completed page 3 of the OSHA 301, “Medical Treatment Information For Work-Related Injury/Illness” to present to the Designated Medical Facilities as authorization for treatment. If page 3 is not provided, the designated medical facility may refuse to treat as a workers’ compensation injury or illness. Submit the completed OSHA 301 to Employee Leaves and Workers' Compensation Unit.
• Immediately complete numbers 11 and 12 on page 3 of the Workers' Compensation Claim Form and Notice of Potential Eligibility - DWC-1 and provide the DWC-1 to the injured employee for completion of numbers 1-6 and 8. Instruct the employee to return the completed form to the Employee Leaves and Workers’ Compensation Unit, Kendall Hall 220 or via fax to 530-898-5755. If you are unable to provide the DWC-1 to the employee, call 530-898-4670 immediately for mailing within 24 hours.

* Serious injuries/illnesses include (but are not limited to): serious lacerations; lumbar (back) strains; knee strains or dislocations; possible bone fractures; loss of consciousness or ambulation; life threatening injuries; and exposure to hazardous substances.

• Supervisors and other employees may not transport ill/injured employees.
• Emergency: call 911 for immediate assistance

If you experience any difficulties in arranging transportation please contact Workers' Compensation 530-898-4670 or Risk Management(opens in new window)530-898-6588.

Designated Medical Facilities

Serious Injury/Illness

Enloe Medical Center Emergency Service

1531 Esplanade, Chico, CA 95926(opens in new window)
Phone: 530-332-7300
Business Hours: 24 hours per day / 7 days per week

Minor Injury/Illness

*Outside ICMC business hours

Any injury/illness occurring after Immediate Care Medical Center, Inc. business hours should be directed to: Enloe Medical Center Emergency Services

Employee has Pre-Designated a Personal Physician, Chiropractor or Acupuncturist

If an employee has pre-designated his or her own personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.), medical group, chiropractor or acupuncturist to act as their primary treating physician for a work-related injury or illness, he or she may obtain medical treatment from his or her own provider.

An employee must have a current Work Related Injury and Illness - Predestination of Personal Physician, Chiropractor or Acupuncturist (for Work-Related Injury or Illness) form naming that provider on file with the The Employee Leaves and Workers' Compensation Unit prior to a work-related injury or illness.