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					               6 EMERGENCIES/SAFETY/HEALTH

GENERAL SAFETY GUIDELINES

One of your primary concerns is, of course, the safety and welfare of the students. You are
responsible for maintaining a safe classroom environment and for providing students with
appropriate safety instruction. In emergencies, buildings, equipment and adult staff
members become secondary to the welfare of students.

Know the emergency and student accident procedures of your district or college!

Be aware of the three differing systems and procedures for dealing with emergency and
student accidents:

       District
       ROP

       Employer related for paid work experience

In cases of student accident or injury, in the campus classroom the rules are set by the
district or college. In the community classroom or lab site, the procedures are dictated by
ROP and the County Office of Education. In a work site where the student is paid, the
procedures are governed by the employer’s insurance carrier.

To prevent student injury and possible legal action, take every possible precaution. (Some
teachers obtain personal liability insurance so that they are adequately covered in case of
legal action.)

Never leave students unsupervised. If, in an emergency, you must leave the class, contact a
coworker or site administrator.

Any question of safety or hazardous conditions should be promptly referred (in writing) to
the administrator responsible for safety.

Intentional violation or continued ignoring of safety rules by a student are just cause for
removal from an ROP program. Procedures for expulsion are explained in Chapter 12.


DISASTER/EMERGENCY PROCEDURES

On a campus, learn the site disaster/emergency preparedness plans. In an emergency try to
keep your attendance roster with you in order to take roll. If a student is injured, render
logical, immediate assistance and immediately contact the school nurse or an administrator.

In case of earthquake, know the basic steps which have been determined by your district or
college.




                                                 6-1               Teacher Handbook Revised 7/14/2011
STUDENT INJURIES/EMERGENCIES

The guidelines below for handling critical and non-critical student injuries or emergencies
are directed to teachers of ROP students who are in community classrooms and in
clinical, laboratory experiences conducted in community sites/agencies. Students in
these situations are covered by workers’ compensation and, for insurance benefits, certain
procedures are required. This coverage does not include travel to or from a training site.
(Workers’ compensation for ROP students is also discussed in Chapter 7.)

These guidelines, although directed to specific ROP teachers, would be appropriate in most
student injury/emergency situations. At school sites and leased training facilities,
observe established district procedures.

Any employer who has an ROP student in a training station at his/her business should also
be advised of procedures which must be observed in case of student injury. You may not
be present or immediately available at such a time.


CRITICAL INJURIES

At non-school sites in case of critical injuries, take these steps:

1. CALL 911 for an ambulance, fire department and/or paramedic assistance.

2. Before the emergency team arrives, render first aid as appropriate.

3. Inform the student of his/her coverage under workers’ compensation.

4. The responding emergency team will determine where to take the injured student.

5. When the injured student’s immediate needs have been met and medical care has been
   obtained, notify your administrator.

6. Complete the Teacher’s/Supervisor’s Report of ROP Student Injury/Emergency, Form
   289 (sample in chapter appendix).

      Obtain Form 289 from your ROP District Designated Representative or from
       a Systems Technician at the county ROP office. Or you may copy the form in
       the chapter appendix and make the three additional distribution copies as
       noted in the lower right corner.

7. Document (in writing) the details of the accident/injury. Include the date, time,
   location, witnesses, safety procedures, safety tests, circumstances of the accident/injury,
   and any other pertinent details.

8. Within 24 hours provide the student with a Workers’ Compensation Claim Form &
   Notice of Potential Eligibility DWC Form 1. (The student in this case is considered the
   employee.) A copy of this form is in the chapter appendix or you may obtain one
   from your district representative or from the county ROP office.

      The student must complete the “employee” section and return it to you
       immediately. You or the site manager must complete the “employer” section.
       The student retains the Notice of Potential Eligibility.

9. Immediately send the completed Form 289 and the completed DWC Form 1 to your
   Systems Technician at the San Diego County ROP office via school mail or to 6401
   Linda Vista Rd., Rm. 408, San Diego,CA 92111-7399.
                                                  6-2                 Teacher Handbook Revised 7/14/2011
NON-CRITICAL INJURIES

The guidelines below pertain to cases of student non-critical injuries/illnesses that require
medical attention. Refer to the list of approved facilities in the chapter appendix to which
injured students can be sent under the present workers’ compensation agreement.
Additionally, have on hand the small Medical Service Order form (copy in chapter
appendix).

At non-school sites:

1. Inform the student of his/her coverage under workers’ compensation.

2. Determine the medical facility to which the student will be sent (see list of approved
   facilities in the chapter appendix) and complete the Medical Service Order form.

      Note: Students are expected to transport themselves or arrange to be transported.
       It is not advisable for you to do so.

3. If the student elects to go to his/her own doctor, inform him/her that the claim may not
   be paid by workers’ compensation.

      Note: For the student to receive workers’ compensation coverage, one of the
       approved medical facilities must be consulted within the first 30 days
       following the injury/emergency.

4. The Doctor’s First Report of Injury noted on the Medical Service Order form is
   completed by the medical facility.

5. Complete the Teacher’s/Supervisor’s Report of ROP Student Injury/Emergency, Form
   289 (sample in chapter appendix).

      Obtain Form 289 from your ROP District Designated Representative or from
       a Systems Technician at the county ROP office. Or you may copy the form in
       the chapter appendix and make the three additional distribution copies as
       noted in the lower right corner.

6. Within 24 hours provide the student with an Employee’s Claim for Workers’
   Compensation Benefits & Notice of Potential Eligibility, DWC Form 1. (The student
   in this case is considered the employee.) A copy of this form is in the chapter
   appendix or you may obtain one from your district representative or from the county
   ROP office. The student retains the Notice of Potential Eligibility.

7. Immediately send the completed Form 289 and the completed DWC Form 1 to your
   Systems Technician at the San Diego County ROP office via school mail or to 6401
   Linda Vista Rd., Rm. 408, San Diego, CA 92111-7399.



FIRST AID TRAINING

Although it is not a legal requirement, all ROP teachers are encouraged to enroll in first aid
and CPR training classes. These are offered through the local Red Cross chapter and other
community agencies.




                                                6-3                Teacher Handbook Revised 7/14/2011
PARENT/GUARDIAN NOTIFICATION

When a high school student becomes ill in your classroom, he/she should be sent to the
school nurse or the parent or guardian should be called to pick up the student. Never send
a student home if the parent/guardian is not consulted. Always observe district procedures.

In case of serious injury to a student, follow district procedures for notifying parents or
guardians. In case of serious injury to an adult student, you will need to learn which
responsible person to notify.


SAFETY FOR OFF-SITE STUDENTS

Personal safety for ROP students who travel to community classroom or cooperative
vocational education training sites is a concern. Consider setting the following rules with
all your community-based students:

      When leaving a bus or car to go to your training site, walk with other students, if at
       all possible.
      When leaving your training site, go directly to a bus or your car.

      If you have any concerns about your personal safety, inform your ROP teacher and,
       if necessary, contact a security person employed in the area.

      If, after training hours, you decide to go shopping or to a movie, be sure to inform
       your parent or guardian.

      If stranded, try to use a telephone inside the building.

      Accept no ride or assistance which would put you in jeopardy.


SECURITY

Know campus security measures and what to do in the event that you have some disruption
or an intruder.

While it may seem an inconvenience, there is justification for having visitors check in at
the office before coming to your classroom.
Take steps to protect all valuable equipment. If possible, lock equipment in cabinets or in a
toolroom. Check that doors and windows are securely locked upon leaving the classroom.

Appointing a student security manager is a good way to get help in this area.




                                                 6-4                Teacher Handbook Revised 7/14/2011
CHILD ABUSE

The California Penal Code mandates that personnel of all schools (both public and private)
be knowledgeable of the child abuse reporting requirements of the state. Reporting is
mandatory when there is observation of, knowledge of, or reasonable suspicion of child
abuse (including sexual abuse).

The law forbids the impeding or inhibiting of these reporting duties by others, including
superiors. This required reporting is protected from both civil and criminal liability.

“Child” means a person under age 18, or age 22 for a special education student.

Suspected child abuse is normally reported to Child Protective Services, Department of
Social Services. When necessary it can also be reported to the police or sheriff’s
department or district attorney’s office.

Notify your site administrator who can determine who shall make the actual report.
Subsequent to the oral report, a submission of a written form will be required.
                          CHILD ABUSE 24-HOUR HOTLINE

                            (858) 560-2191 or no charge to caller

                                      1-800-344-6000


ADULT ABUSE

To make a referral or to report suspected abuse or neglect of a dependent adult, first notify
your site administrator. Again, the administration must determine who shall make the
report.

“Dependent adult” is one 18 or older who is at risk or in danger of exploitation, abuse or
neglect.

                          ADULT ABUSE 24-HOUR HOTLINE

                                      1-800-523-6444

EMPLOYEE INJURIES

As an ROP teacher, you are covered by your district’s workers’ compensation for
accidental injuries suffered while on the job. Responsibility for timely reporting of
accidental work-related injuries rests with you.

Consult your district personnel office, site administrator or ROP district representative for
information regarding other insurance coverage you may have.

INFECTIOUS DISEASE

School districts are required by law to provide staff members with guidelines regarding
precautions to take to prevent the spread of infectious diseases. Contact your site
administrator or ROP district representative if you need a copy of this information.

ROP teachers of human and animal health subjects should advise students of potential risks
and provide appropriate training along with tests for student safety and well-being. Some


                                                6-5                 Teacher Handbook Revised 7/14/2011
teachers of such courses require adult students and parents of those under 18 to sign
informed consent forms. (See sample in chapter appendix.)

Ensure the use of gloves, masks, protective eyewear and gowns (appropriate to the setting)
by all students when working with body fluids and mucous membrane tissue. All ROP
medical/dental teachers should provide their students with the most current and accurate
information on the risks and hazards of dealing with patients who may/may not be
identified as carriers of infectious diseases..

Instruction and tests should include:

      The latest infectious disease control methodologies

      The application and use of protective aseptic measures

HAZARDOUS/INFECTIOUS WASTE

You and your students have the right to receive information about hazardous substances to
which you might be exposed and how to protect yourselves from their physical and health
hazards.

For each liquid material/chemical stored on site, teachers must have on file a Material
Safety Data Sheet (MSDS). (An MSDS can be requested from vendors when items are
purchased.)

The MSDS identifies the product, lists hazardous ingredients, describes physical data,
reports fire and explosion hazards and health hazards, reports reactivity, spill or leak
procedures, special protection and precautions.

Infectious waste is another item of serious concern to teachers of medical/dental/animal
science classes.

Teachers are being held liable for the proper disposal of both hazardous and infectious
wastes and for accounting for such disposal. Consult your site administrator or ROP
District Designated Representative for district policy and procedures regarding these
matters.

EYE PROTECTION

The Education Code requires that eye protective devices be provided for all classes which
present any potential injury to the eyes from equipment or materials used in the class. The
law makes it your duty to require that such devices (not regular eyeglasses) be worn.

STUDENT ON PRESCRIBED MEDICATION

If a student under age 18 needs to take prescribed medication during an ROP class, most
districts have strict procedures requiring written statements from the physician and
parent/guardian. In most cases administering medication to a student is done by a school
nurse or other assigned staff. Know the rules!

If you have reason to suspect “medication” is anything other than that, consult your site
administrator, counselor or ROP district representative.




                                                6-6               Teacher Handbook Revised 7/14/2011
Appendix
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad
If you are injured or become ill, either physically or mentally, because of    Si Ud. se lesiona o se enferma, ya sea físicamente o mentalmente, debido a
your job, including injuries resulting from a workplace crime, you may be      su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de
entitled to workers’ compensation benefits. Attached is the form for filing    trabajo, es posible que Ud. tenga derecho a beneficios de compensación de
a workers’ compensation claim with your employer. You should read all          trabajadores. Se adjunta el formulario para presentar un reclamo de
of the information below. Keep this sheet and all other papers for your        compensación de trabajadores con su empleador. Ud. debe leer toda la
records. You may be eligible for some or all of the benefits listed            información a continuación. Guarde esta hoja y todos los demás
depending on the nature of your claim. If required you will be notified by     documentos para sus archivos. Es posible que usted reúna los requisitos
the claims administrator, who is responsible for handling your claim,          para todos los beneficios, o parte de éstos, que se enumeran, dependiendo
about your eligibility for benefits.                                           de la índole de su reclamo. Si se requiere, el administrador de reclamos,
                                                                               quien es responsable por el manejo de su reclamo, le notificará sobre su
To file a claim, complete the “Employee” section of the form, keep one         elegibilidad para beneficios.
copy and give the rest to your employer. Your employer will then
complete the “Employer” section, give you a dated copy, keep one copy          Para presentar un reclamo, llene la sección del formulario designada para el
and send one to the claims administrator. Benefits can’t start until the       “Empleado,” guarde una copia, y déle el resto a su empleador. Entonces,
claims administrator knows of the injury, so complete the form as soon as      su empleador completará la sección designada para el “Empleador,” le dará
possible.                                                                      a Ud. una copia fechada, guardará una copia, y enviará una al
                                                                               administrador de reclamos. Los beneficios no pueden comenzar hasta, que
Medical Care: Your claims administrator will pay all reasonable and            el administrador de reclamos se entere de la lesión, así que complete el
necessary medical care for your work injury or illness. Medical benefits       formulario lo antes posible.
may include treatment by a doctor, hospital services, physical therapy, lab
tests, x-rays, and medicines. Your claims administrator will pay the costs     Atención Médica: Su administrador de reclamos pagará toda la atención
directly so you should never see a bill. There is a limit on some medical      médica razonable y necesaria, para su lesión o enfermedad relacionada con
services.                                                                      el trabajo. Es posible que los beneficios médicos incluyan el tratamiento
                                                                               por parte de un médico, los servicios de hospital, la terapia física, los
The Primary Treating Physician (PTP) is the doctor with the overall            análisis de laboratorio y las medicinas. Su administrador de reclamos
responsibility for treatment of your injury or illness. Generally your         pagará directamente los costos, de manera que usted nunca verá un cobro.
employer selects the PTP you will see for the first 30 days, however, in       Hay un límite para ciertos servicios médicos.
specified conditions, you may be treated by your predesignated doctor or
medical group. If a doctor says you still need treatment after 30 days, you    El Médico Primario que le Atiende-Primary Treating Physician PTP es
may be able to switch to the doctor of your choice. Different rules apply if   el médico con la responsabilidad total para tratar su lesión o enfermedad.
your employer is using a Health Care Organization (HCO) or a Medical           Generalmente, su empleador selecciona al PTP que Ud. verá durante los
Provider Network (MPN). A MPN is a selected network of health care             primeros 30 días. Sin embargo, en condiciones específicas, es posible que
providers to provide treatment to workers injured on the job. You should       usted pueda ser tratado por su médico o grupo médico previamente
receive information from your employer if you are covered by an HCO or         designado. Si el doctor dice que usted aún necesita tratamiento después de
a MPN. Contact your employer for more information. If your employer            30 días, es posible que Ud. pueda cambiar al médico de su preferencia. Hay
has not put up a poster describing your rights to workers’ compensation,       reglas differentes que se aplican cuando su empleador usa una
you may choose your own doctor immediately.                                    Organización de Cuidado Médico (HCO) o una Red de Proveedores
                                                                               Médicos (MPN). Una MPN es una red de proveedores de asistencia médica
Within one working day after you file a claim form, your employer shall        seleccionados para dar tratamiento a los trabajadores lesionados en el
authorize the provision of all treatment, consistent with the applicable       trabajo. Usted debe recibir información de su empleador si su tratamiento
treating guidelines, for the alleged injury and shall continue to be liable    es cubierto por una HCO o una MPN. Hable con su empleador para más
for up to $10,000 in treatment until the claim is accepted or rejected.        información. Si su empleador no ha colocado un cartel describiendo sus
                                                                               derechos para la compensación de trabajadores, Ud. puede seleccionar a su
Disclosure of Medical Records: After you make a claim for workers'             propio médico inmediatamente.
compensation benefits, your medical records will not have the same level
of privacy that you usually expect. If you don’t agree to voluntarily          Dentro de un día después de que Ud. Presente un formulario de reclamo, su
release medical records, a workers’ compensation judge may decide what         empleador autorizará todo tratamiento médico de acuerdo con las pautas de
records will be released. If you request privacy, the judge may "seal"         tratamiento aplicables a la presunta lesión y será responsable por $10,000
(keep private) certain medical records.                                        en tratamiento hasta que el reclamo sea aceptado o rechazado.

Payment for Temporary Disability (Lost Wages): If you can't work               Divulgación de Expedientes Médicos: Después de que Ud. presente un
while you are recovering from a job injury or illness, for most injuries you   reclamo para beneficios de compensación de trabajadores, sus expedientes
will receive temporary disability payments for a limited period of time.       médicos no tendrán el mismo nivel de privacidad que usted normalmente
These payments may change or stop when your doctor says you are able           espera. Si Ud. no está de acuerdo en divulgar voluntariamente los
to return to work. These benefits are tax-free. Temporary disability           expedientes médicos, un juez de compensación de trabajadores
payments are two-thirds of your average weekly pay, within minimums            posiblemente decida qué expedientes se revelarán. Si Ud. solicita
and maximums set by state law. Payments are not made for the first three       privacidad, es posible que el juez “selle” (mantenga privados) ciertos
days you are off the job unless you are hospitalized overnight or cannot       expedientes médicos.
work for more than 14 days.
                                                                               Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede
Return to Work: To help you to return to work as soon as possible, you         trabajar, mientras se está recuperando de una lesión o enfermedad
should actively communicate with your treating doctor, claims                  relacionada con el trabajo, Ud. recibirá pagos por incapacidad temporal
administrator, and employer about the kinds of work you can do while           para la mayoría de las lesions por un period limitado. Es posible que estos
recovering. They may coordinate efforts to return you to modified duty or      pagos cambien o paren, cuando su médico diga que Ud. está en condiciones
other work that is medically appropriate. This modified or other duty may      de regresar a trabajar. Estos beneficios son libres de impuestos. Los pagos
Rev. 6/10
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad
be temporary or may be extended depending on the nature of your injury          por incapacidad temporal son dos tercios de su pago semanal promedio,
or illness.                                                                     con cantidades mínimas y máximas establecidas por las leyes estatales.
                                                                                Los pagos no se hacen durante los primeros tres días en que Ud. no trabaje,
Payment for Permanent Disability: If a doctor says your injury or               a menos que Ud. sea hospitalizado una noche o no pueda trabajar durante
illness results in a permanent disability, you may receive additional           más de 14 días.
payments. The amount will depend on the type of injury, your age,
occupation, and date of injury.                                                 Regreso al Trabajo: Para ayudarle a regresar a trabajar lo antes posible,
                                                                                Ud. debe comunicarse de manera activa con el médico que le atienda, el
Supplemental Job Displacement Benefit (SJDB): If you were injured               administrador de reclamos y el empleador, con respecto a las clases de
after 1/1/04 and you have a permanent disability that prevents you from         trabajo que Ud. puede hacer mientras se recupera. Es posible que ellos
returning to work within 60 days after your temporary disability ends, and      coordinen esfuerzos para regresarle a un trabajo modificado, o a otro
your employer does not offer modified or alternative work, you may              trabajo, que sea apropiado desde el punto de vista médico. Este trabajo
qualify for a nontransferable voucher payable to a school for retraining        modificado u otro trabajo podría ser temporal o podría extenderse
and/or skill enhancement. If you qualify, the claims administrator will         dependiendo de la índole de su lesión o enfermedad.
pay the costs up to the maximum set by state law based on your
percentage of permanent disability.                                             Pago por Incapacidad Permanente: Si el doctor dice que su lesión o
                                                                                enfermedad resulta en una incapacidad permanente, es posible que Ud.
Death Benefits: If the injury or illness causes death, payments may be          reciba pagos adicionales. La cantidad dependerá de la clase de lesión, su
made to relatives or household members who were financially dependent           edad, su ocupación y la fecha de la lesión.
on the deceased worker.
                                                                                Beneficio Suplementario por Desplazamiento de Trabajo: Si Ud. Se
It is illegal for your employer to punish or fire you for having a job          lesionó después del 1/1/04 y tiene una incapacidad permanente que le
injury or illness, for filing a claim, or testifying in another person's        impide regresar al trabajo dentro de 60 días después de que los pagos por
workers' compensation case (Labor Code 132a). If proven, you may                incapacidad temporal terminen, y su empleador no ofrece un trabajo
receive lost wages, job reinstatement, increased benefits, and costs and        modificado o alternativo, es posible que usted reúna los requisitos para
expenses up to limits set by the state.                                         recibir un vale no-transferible pagadero a una escuela para recibir un nuevo
                                                                                entrenamiento y/o mejorar su habilidad. Si Ud. reúne los requisitios, el
You have the right to disagree with decisions affecting your claim. If you      administrador de reclamos pagará los gastos hasta un máximo establecido
have a disagreement, contact your claims administrator first to see if you      por las leyes estatales basado en su porcentaje de incapacidad permanente.
can resolve it. If you are not receiving benefits, you may be able to get
State Disability Insurance (SDI) benefits. Call State Employment                Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es
Development Department at (800) 480-3287.                                       posible que los pagos se hagan a los parientes o a las personas que viven en
                                                                                el hogar y que dependían económicamente del trabajador difunto.
You can obtain free information from an information and assistance
officer of the State Division of Workers' Compensation (DWC), or you            Es ilegal que su empleador le castigue o despida, por sufrir una lesión o
can hear recorded information and a list of local offices by calling (800)      enfermedad en el trabajo, por presentar un reclamo o por testificar en el
736-7401. You may also go to the DWC website at www.dwc.ca.gov.                 caso de compensación de trabajadores de otra persona. (El Codigo Laboral
                                                                                sección 132a.) De ser probado, usted puede recibir pagos por pérdida de
You can consult with an attorney. Most attorneys offer one free                 sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los
consultation. If you decide to hire an attorney, his or her fee will be taken   límites establecidos por el estado.
out of some of your benefits. For names of workers' compensation
attorneys, call the State Bar of California at (415) 538-2120 or go to their    Ud. tiene derecho a no estar de acuerdo con las decisiones que afecten su
web site at www.californiaspecialist.org.                                       reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con su
                                                                                administrador de reclamos para ver si usted puede resolverlo. Si usted no
                                                                                está recibiendo beneficios, es posible que Ud. pueda obtener beneficios del
                                                                                Seguro Estatal de Incapacidad (SDI). Llame al Departamento Estatal del
                                                                                Desarrollo del Empleo (EDD) al (800) 480-3287.

                                                                                Ud. puede obtener información gratis, de un oficial de información y
                                                                                asistencia, de la División Estatal de Compensación de Trabajadores
                                                                                (Division of Workers’ Compensation – DWC) o puede escuchar
                                                                                información grabada, así como una lista de oficinas locales llamando al
                                                                                (800) 736-7401. Ud. también puede consultar con la pagína Web de la
                                                                                DWC en www.dwc.ca.gov.

                                                                                Ud. puede consultar con un abogado. La mayoría de los abogados
                                                                                ofrecen una consulta gratis. Si Ud. decide contratar a un abogado, los
                                                                                honorarios serán tomados de algunos de sus beneficios. Para obtener
                                                                                nombres de abogados de compensación de trabajadores, llame a la
                                                                                Asociación Estatal de Abogados de California (State Bar) al (415) 538-
                                                                                2120, ó consulte con la pagína Web en www.californiaspecialist.org.




Rev. 6/10
State of California                                                                                                                      Estado de California
Department of Industrial Relations                                                                                     Departamento de Relaciones Industriales
DIVISION OF WORKERS’ COMPENSATION                                                                             DIVISION DE COMPENSACIÓN AL TRABAJADOR

 WORKERS’ COMPENSATION CLAIM FORM (DWC 1)                                                PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
                                                                                                        TRABAJADOR (DWC 1)

Employee: Complete the “Employee” section and give the form to                 Empleado: Complete la sección “Empleado” y entregue la forma a su
your employer. Keep a copy and mark it “Employee’s Temporary                   empleador. Quédese con la copia designada “Recibo Temporal del
Receipt” until you receive the signed and dated copy from your em -            Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
ployer. You may call the Division of Workers’ Compensation and                 Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736-
hear recorded information at (800) 736-7401. An explanation of work-
ers' compensation benefits is included as the cover sheet of this form.        7401 para oir información gravada. En la hoja cubierta de esta
                                                                               forma esta la explicatión de los beneficios de compensación al trabajador.
You should also have received a pamphlet from your employer de-
scribing workers’ compensation benefits and the procedures to obtain           Ud. también debería haber recibido de su empleador un folleto describiendo los
them.                                                                          benficios de compensación al trabajador lesionado y los procedimientos para
                                                                               obtenerlos.

Any person who makes or causes to be made any knowingly false                  Toda aquella persona que a propósito haga o cause que se produzca
or fraudulent material statement or material representation for                cualquier declaración o representación material falsa o fraudulenta con el
the purpose of obtaining or denying workers’ compensation bene-                fin de obtener o negar beneficios o pagos de compensación a trabajadores
fits or payments is guilty of a felony.                                        lesionados es culpable de un crimen mayor “felonia”.

Employee—complete this section and see note above              Empleado—complete esta sección y note la notación arriba.

1.    Name. Nombre. _____________________________________________Today’s Date. Fecha de Hoy.                         ___________________________________
2.    Home Address. Dirección Residencial. _______________________________________________________________________________________
3.    City. Ciudad. _______________________________________ State. Estado. __________________                        Zip. Código Postal. ___________________
4.    Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _________a.m. ________p.m.
5.    Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _________________________________________
      _______________________________________________________________________________________________________________________
6.    Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _______________________________________________
      _______________________________________________________________________________________________________________________
7.    Social Security Number. Número de Seguro Social del Empleado.          _______________________________________________________________
8.    Signature of employee. Firma del empleado.      _________________________________________________________________________________

Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.

9.                                          San Diego County Office of Education / ROP
    Name of employer. Nombre del empleador. ___________________________________________________________________________________
                        6401 Linda Vista Road, San Diego CA 92111
10. Address. Dirección. _____________________________________________________________________________________________________
11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. _____________________________
12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. _________________________________________
13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _______________________________________
14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros.
    Corvel Corp. 8787 Complex Dr. 3rd Floor, San Diego CA 92123
    _______________________________________________________________________________________________________________________
15. Insurance Policy Number. El número de la póliza de Seguro. _____________________________________________________________________
16. Signature of employer representative. Firma del representante del empleador. _______________________________________________________
                   ROP Business Manager                                                  (858) 569-5303
17. Title. Título. _____________________________________ 18. Telephone. Teléfono. _______________________________________________


Employer: You are required to date this form and provide copies to          Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su com-
your insurer or claims administrator and to the employee, dependent         pañía de seguros, administrador de reclamos, o dependiente/representante de recla-
or representative who filed the claim within one working day of             mos y al empleado que hayan presentado esta petición dentro del plazo de un día
receipt of the form from the employee.                                      hábil desde el momento de haber sido recibida la forma del empleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY                          EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD

❑ Employer copy/Copia del Empleador   ❑ Employee copy/ Copia del Empleado    ❑ Claims Administrator/Administrador de Reclamos   ❑ Temporary Receipt/Recibo del Empleado

6/10 Rev.
                                  CorVel Corporation                                                                          CorVel Corporation
                           5694 Mission Center Road, Box 700                                                           5694 Mission Center Road, Box 700
                                 San Diego, CA 92108                                                                         San Diego, CA 92108
                (858) 300-2500 FAX (858) 300-2560 1 (800) 757-7100                                          (858) 300-2500 FAX (858) 300-2560 1 (800) 757-7100

                              MEDICAL SERVICE ORDER                                                                       MEDICAL SERVICE ORDER

To Doctor ________________________________________________________________                  To Doctor ________________________________________________________________
(address) _________________________________________________________________                 (address) _________________________________________________________________
(employee) __________________________________________________ was injured on                (employee) __________________________________________________ was injured on
(date) ____________________ at (time) _________________ while in our employ.                (date) ____________________ at (time) _________________ while in our employ.
Please give necessary medical care immediately, then complete and send the Doctor's First   Please give necessary medical care immediately, then complete and send the Doctor's First
Report of Work Injury to CorVel Corporation.                                                Report of Work Injury to CorVel Corporation.

(employer) _______________________________________________________________                  (employer) _______________________________________________________________
(address) ________________________________________________________________                  (address) _________________________________________________________________
(signed by) _________________________________________ (title) ________________              (signed by) _________________________________________ (title) _________________
(date) ___________________________________________________________________                  (date) ___________________________________________________________________

                         One time visit only – call for authorization                                                One time visit only – call for authorization



                                  CorVel Corporation                                                                          CorVel Corporation
                           5694 Mission Center Road, Box 700                                                           5694 Mission Center Road, Box 700
                                 San Diego, CA 92108                                                                         San Diego, CA 92108
                (858) 300-2500 FAX (858) 300-2560 1 (800) 757-7100                                          (858) 300-2500 FAX (858) 300-2560 1 (800) 757-7100

                              MEDICAL SERVICE ORDER                                                                       MEDICAL SERVICE ORDER

To Doctor ________________________________________________________________                  To Doctor ________________________________________________________________
(address) _________________________________________________________________                 (address) _________________________________________________________________
(employee) __________________________________________________ was injured on                (employee) __________________________________________________ was injured on
(date) ____________________ at (time) _________________ while in our employ.                (date) ____________________ at (time) _________________ while in our employ.
Please give necessary medical care immediately, then complete and send the Doctor's First   Please give necessary medical care immediately, then complete and send the Doctor's First
Report of Work Injury to CorVel Corporation.                                                Report of Work Injury to CorVel Corporation.

(employer) _______________________________________________________________                  (employer) _______________________________________________________________
(address) ________________________________________________________________                  (address) _________________________________________________________________
(signed by) _________________________________________ (title) ________________              (signed by) _________________________________________ (title) _________________
(date) ___________________________________________________________________                  (date) ___________________________________________________________________

                         One time visit only – call for authorization                                                One time visit only – call for authorization
US Healthworks Medical Group

                           Kearny Mesa
                           5575 Ruffin Road, Suite 100
                           San Diego, CA 92123             U
                           (858) 277-2744                  S
                           Open: 24 Hours/7 Days a Week

                                                           H
                                                           E
                                                           A
                                                           L
                           Vista                           T
                           2023 West Vista Way, Suite C    H
                           Vista, CA 92083
                           (760) 941-2000                  W
                           Open: M-F 8am-5pm               O
                                                           R
                                                           K
                                                           S

                                                           M
                           Hillcrest
                           3930 Fourth Avenue, Suite 200   E
                           San Diego, CA 92103             D
                           (619) 297-9610
                           Open: M-F 7am-7pm               I
                                                           C
                                                           A
                                                           L

                                                           G
                           National City                   R
                           102 Mile of Cars Way
                           National City, CA 91950         O
                           (619) 474-9211                  U
                           Open: M-F 7am-7pm
                                                           P
Sorrento Mesa
5897 Oberlin Drive, Suite 100
San Diego, CA 92121
(858) 455-0200                       U
Open: M-F 8am-5pm
                                     S

                                     H
                                     E
                                     A
Escondido                            L
362 West Mission Avenue, Suite 104
Escondido, CA 92025                  T
(760) 747-2330                       H
Open: M-F 8am-5pm
                                     W
                                     O
                                     R
                                     K
                                     S
La Mesa
8090 Parkway Drive
La Mesa, CA 91942                    M
(619) 697-3093                       E
Open: M-F 8am-7pm
                                     D
                                     I
                                     C
                                     A
                                     L
Chula Vista
111 Broadway, Suite 305
Chula Vista, CA 91911                G
(619) 425-8212                       R
Open: M-F 8am-6pm
                                     O
                                     U
                                     P
Miramar
7590 Miramar Road, Suite C
San Diego, CA 92126
(858) 549-4255
Open: M-F 8am-5pm                 U
                                  S

                                  H
                                  E
Carlsbad                          A
5814 Van Allen Way, Suite 210     L
Carlsbad, CA 92008
(760) 438-4466                    T
Open: M-F 8am-6pm                 H
                                  W
                                  O
                                  R
                                  K
                                  S
Santee
9745 Prospect Avenue
Santee, CA 92071                  M
(619) 448-4841                    E
Open: M-F 7am-6pm
                                  D
                                  I
                                  C
                                  A
                                  L
San Diego                         G
U.S. Healthworks Medical Clinic
3930 Fourth Avenue, Ste. 200      R
San Diego, CA 92103               O
(619) 297-9610
Open: M-F 7am-7pm                 U
                                  P
Kearney Mesa
U.S. Healthworks Medical Clinic
8315 Century Park Court
San Diego, CA 92123
(619) 277-2744/565-1300           U
Open: 24 Hrs./7 Days a Week
                                  S

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                                  T
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                                  O
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                                  K
                                  S

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Sharp Rees-Stealy
Occupational Health Facilities
                                 Chula Vista
                                 525 Third Ave.
                                 Chula Vista, CA 91910
                                 (619) 585-4050
                                 Open: M-F 7am-6pm




                                                           S
                                                           H
                                 Downtown
                                 2001 Fourth Ave.          A
                                 San Diego, CA 92101       R
                                 (619) 699-1524            P
                                 Open: M-F 8am-5pm

                                                           R
                                                           E
                                                           E
                                                           S
                                                           -
                                 Kearny Mesa               S
                                 2020 Genesee Avenue       T
                                  San Diego, CA 92123
                                  858-616-8400
                                                           E
                                  Open: M-F 7am-5pm        A
                                                           L
                                                           Y




                                 La Mesa
                                 Grossmont Medical Plaza
                                 5525 Grossmont Ctr. Dr.
                                 La Mesa, CA 91942
                                 (619) 644-6600
                                 Open: M-F 8am-5pm
Mira Mesa
8901 Activity Road
San Diego, CA 92126
(858) 653-6150
Open: M-F 8am-5pm




                                  S
Rancho Bernardo
16950 Via Tazon                   H
San Diego, CA 92127               A
(858) 521-2350                    R
Open: M-F 8am-5pm
                                  P

                                  R
                                  E
                                  E
                                  S
Sharp Mission Park                -
130 Cedar Rd., #200
Vista, CA 92083                   S
(760) 806-5550                    T
Open: M-F 8am-5pm
                                  E
                                  A
                                  L
                                  Y


Carmel Valley
Sharp Rees-Stealy Medical Group
12710 Carmel Country Rd.
San Diego, CA 92130
(619) 794-3888
Open: M-F 8am-5pm
El Cajon
Sharp Rees-Stealy Medical Group
1240 Broadway Ave.
El Cajon, CA 92021
(619) 441-6350
Open: M-F 8am-5pm




                                  S
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                                  Y
Kaiser Permanente
Occupational Health Services
(For Workers’ Compensation)
                               San Diego Medical Center
                               4647 Zion Avenue
                               San Diego, CA 92120
                               (619) 528-5062
                               Open: M-F 7am-7pm




                                                           K
                                                           A
                                                           I
                                                           S
                               Otay Mesa Medical Office
                               4650 Palm Avenue            E
                               San Diego, CA 92173         R
                               (619) 662-5006
                               Open: M-F 9am-5pm
                                                           P
                                                           E
                                                           R
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                                                           A
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                                                           E
                               San Marcos Medical Office   N
                               400 Craven Road             T
                               San Marcos, CA 92078
                               (760) 510-5350
                                                           E
                               Open: M-F 9am-5pm
AMERICAN OCCUPATIONAL MEDICINE (AOM)
                      ESCONDIDO                      A
                      860 W. Valley Parkway, #150
                      Escondido CA 92025             M
                      (760) 740-0707                 E
                      (760) 740-0730 fax             R
                      M-F 7:00 am-7:00 pm
                      Sat. 9:00 am-2:00 pm           I
                                                     C
                                                     A
                                                     N

                                                     O
                                                     C
                      CARLSBAD                       C
                      5810 El Camino Real, Suite A   U
                      Carlsbad CA 92008
                      (760) 929-8269                 P
                      (760) 929-8556                 A
                      M-F 7:00 am – 6:00 pm          T
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                                                     (A
                                                     O
                                                     M)
      FOR A WORK-RELATED INJURY OR ILLNESS
               Send Employee to the Nearest
    Sharp Rees-Stealy Occupational Health Services Facility

                SHARP REES-STEALY                N
                                                                        SHARP REES-STEALY
                CHULA VISTA                                             LA MESA
                525 Third Ave.                                          Grossmont Medical Plaza
                Chula Vista, CA 91910                                   5525 Grossmont Center Drive,
                (619) 585-4050                                          Suite 601
                Occupational Health Services                            La Mesa, CA 91942
                7 a.m. to 5 p.m., Mon. to Fri.                          (619) 644-6600
                Urgent Care Services                                    Occupational Health Services
                                                                        8 a.m. to 5 p.m., Mon. to Fri.
                8 a.m. to 8 p.m., daily
                                                                        Urgent Care Services
                                                                        8 a.m. to 8 p.m., daily




                SHARP REES-STEALY                                       SHARP REES-STEALY
                DOWNTOWN                                                MIRA MESA
                2001 Fourth Ave.                                        8901 Activity Road
                San Diego, CA 92101                                     San Diego, CA 92126
                (619) 446-1524                                          (858) 653-6150
                Occupational Health Services                            Occupational Health Services
                8 a.m. to 5 p.m., Mon. to Fri.                          8 a.m. to 5 p.m., Mon. to Fri.
                Urgent Care Services                                    Urgent Care Services
                8 a.m. to 10 p.m., daily                                8 a.m. to 8 p.m., daily


N




                SHARP REES-STEALY                                       SHARP REES-STEALY
                GENESEE                                                 RANCHO BERNARDO
                2020 Genesee Ave.                                       16950 Via Tazon
                San Diego, CA 92123                                     San Diego, CA 92127
                (858) 616-8400                                          (858) 521-2350
                Occupational Health Services                            Occupational Health Services
                7 a.m. to 5 p.m., Mon. to Fri.                          8 a.m. to 5 p.m., Mon. to Fri.
                Urgent Care Services available                          Urgent Care Services
                at Sharp Rees-Stealy Downtown                           8 a.m. to 8 p.m., daily
                and Mira Mesa locations




        See Reverse for Sharp Hospital Emergency Department Locations
Referral                                      for
                                                         Kaiser on the Job



This referral form will assure prompt treatment for your injured employee. Please be sure that this
form is completed and signed by the injured employee’s supervisor or company representative.
Once the employee is treated, we will promptly inform you of his or her status.

Employee’s name _______________________________________________________________

Supervisor’s name ______________________________________________________________

Employer ______________________________________________________________________

Address _______________________________________________________________________

City _____________________________________ State __________________ Zip __________

Phone ________________________________________________________________________

Nature of injury _________________________________________________________________

How did injury occur _____________________________________________________________

Date and time of injury ___________________________________________________________

Supervisor’s signature ___________________________________________________________
                                                                                 4   Murrieta
                                                         Oceanside                   Approximately 35 miles North on I-15
                                                 2

             North County
     1       Carlsbad
             5810 El Camino Real, Ste. A
             (760) 929-8269
                                                     1
     2       Oceanside                                                                              t Vall
                                                                                                             ey P
                                                                                                                    ark w
                                                                                                                            ay




                                                         El
                                                                                             We s
             3910 Vista Way, Ste. 106                                                    3




                                                         Ca
                                                          min
             (760) 941-2000




                                                              oR
                                                                ea
                                                                l
     3       Escondido
             860 West Valley Parkway, Ste. 150
             (760) 740-0707

     4       Murrieta
             25285 Madison Ave., Ste. 101
             (951) 600-9070

             San Diego
     5       Kearny Mesa
             5575 Ruffin Rd., Ste. 100
             (858) 277-2744

     6 Hillcrest
             3930 Fourth Ave., Ste. 200
             (619) 297-9610

     7 Miramar
             7590 Miramar Rd., Ste. C
             (858) 549-4255

     8 Sorrento Mesa
             5897 Oberlin Dr., Ste. 100                              8       7
             (858) 455-0200

             South County
     9 National City
             102 Mile of Cars Way                                                5
             (619) 474-9211
                                                                                                                                      12
    10 Chula Vista
             1111 Broadway, Ste. 305
             (619) 425-8212                                                                                                      11


             East County
    11 La Mesa
             8090 Parkway Dr.                                            6
             (619) 697-3093

    12 Santee
             9745 Prospect Ave., Ste. 100
             (619) 448-4841




                                                                                        9
         •   Occupational Medicine
         •   Urgent Care
         •   Specialty Care
         •   Therapy Services
                                                                                                                      10
         www.ushealthworks.com

Rev. 07/25/2011
                                 1
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                                         El
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                                         Ca
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                                          min
                                              oR
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                                                l
                     Random Drug Testing Locations

  San Diego
1 Kearny Mesa
  5575 Ruffin Rd., Ste. 100
  (858) 277-2744
  Open 24 hours a day,
  7 days a week
2 Hillcrest
  3930 Fourth Ave., Ste. 200
  (619) 297-9610
  M-F 7am-7pm                                        4
                                                             3
3 Miramar
  7590 Miramar Rd., Ste. C
  (858) 549-4255
  M-F 8am-5pm
4 Sorrento Mesa
  5897 Oberlin Dr., Ste. 100                                     1
  (858) 455-0200
  M-F 8am-5pm                                                                                                    8


                                                                                                             7

  South County
5 National City
  102 Mile of Cars Way
  (619) 474-9211                                         2
  M-F 7am-9pm
6 Chula Vista
  1111 Broadway, Ste. 305
  (619) 425-8212
  M-F 8am-6pm
  Sat 9am-3pm



  East County                                                        5
7 La Mesa
  8090 Parkway Dr.
  (619) 697-3093
  M-F 8am-5pm
  Sat 10am-3pm
8 Santee                                                                                            6
  9745 Prospect Ave., Ste. 100
  (619) 448-4841
  M-F 7am-6pm

				
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