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					       Injury/Illness Accident Investigation
                                                                       MDUSD Payroll
                                                         If your health care provider feels that you may   MT. DIABLO UNIFIED
   •    Because the District’s goal is to be             need a few days away from work and you have        SCHOOL DISTRICT
        pro-active and work towards injury               questions about your pay and/or Education Code
        prevention, your Site Administrator/             Benefit, our Workers’ Compensation Payroll
        Supervisor, Manager or Office Manager will       Team Member can assist you. Please feel free
        work with you to complete the Injury/Illness     to contact her:
        Accident Investigation process.                                                                       Workers’
        You will be given an Employee Report of
                                                         Michele Landini
   •
        Injury/Illness form to complete. This report     Ext. 4077                                          Compensation
        will ask you for your recollection of the        landinim@mdusd.k12.ca.us
        specifics of your injury/illness.

   •    Your Site Administrator/Supervisor,              Please note: If you have questions                 What To Do If
        Manager or Office Manager may request            about Workers’ Compensation at
        your input, opinion and assistance in
        completing their portion of the investigation
                                                         MDUSD, please contact:                            You Are Injured
        as well.
                                                         Barbara Corrick                                      At Work
   •    The District will ask for your opinion on you    Workers’ Compensation Manager
        how the injury/illness could have been           corrickb@mdusd.k12.ca.us
        prevented and your ideas on how to               Ext. 4163
        prevent the same type of injury/illness from
        happening in the future.                         OR
                                                         Martha Dreisbach
          “Safety is No Accident”                        Workers’ Compensation Assistant
                                                         Ext. 4005
                                                         dreisbachm@mdusd.k12.ca.us

        Cut Here for Wallet Sized Card
---------------------------------------                  MT. DI AB LO
       MDUSD Health Care Providers                       UNI FI E D
                                                         S CH O O L DI S T RI C T
Kaiser Permanente
Walnut Creek Shadelands Occ. Health (925) 906-2060
Antioch Occupational Health (925) 779-5434
Martinez Occupational Health (925) 313-0301              Barbara Corrick
Emergency or After Hours (925) 295-4820                  Workers’ Compensation Manager
                                                         1936 Carlotta Drive
Muir Diablo Occupational Medicine
Galaxy Ct. Concord (925) 685-7744                        Phone: (925) 682-8000 ext. 4163                    Mt. Diablo Unified School District
Broadway St. Walnut Creek (925) 932-7715
Emergency or After Hours                                 Fax: (925) 676-4092                                                is
John Muir Medical Center, Walnut Creek: (925) 939-3000   E-mail: corrickb@mdusd.k12.ca.us                         “Focused on Safety”
John Muir Medical Center, Concord: (925) 682-8200


                                                                      September 2008
    What to do if you are injured at work:               MDUSD Workers’ Compensation                 Our Claims Administration Team
                                                            Health Care Providers
•   If you experience an injury at work, it is
    critical that you notify your Site               Kaiser Permanente:
                                                                                                MDUSD Workers’ Compensation claims with a
    Administrator/Supervisor/Manager                                                            date of injury of 07/01/07 or later are
                                                     •    Park Shadelands Occupational Health
    IMMEDIATELY!                                                                                administered by TriStar Risk Management
•   If medical treatment is necessary, you must      320 Lennon Lane, Lassen Bldg.              (TriStar), Walnut Creek Office. If you have
    seek treatment at one of the providers listed    Walnut Creek 94598 (925) 906-2060          a question about a claim with a date of injury
    unless, prior to the injury, a Pre-Designation                                              07/01/07 or later please contact them at:
    of Personal Physician Form is on file with       •    Antioch Occupational Health
    your site and the Workers’ Compensation                                                     (925) 930-9883
    Office at the District Office. These forms are   3400 Delta Fair Blvd. Adobe Bldg.
                                                                                                Cathy Gilman, Ext. 1831
    available at every school site and
                                                     Antioch 94509 (925) 779-5434
    department or the MDUSD web site under                                                      Stacy Onyett, Ext. 1849
    Workers’ Compensation. You may also              •    Martinez Occupational Health
    obtain one by calling W orkers’                                                             MDUSD Workers’ Compensation claims with a
    Compensation at ext. 4163 or 4005. Note:         200 Muir Rd. Hacienda Bldg.                date of injury 06/30/07 or before are
    you MUST bring a copy of the work status                                                    administered by Contra Costa County
    form from your Health Care         Provider to   Martinez 94553 (925) 313-0301              Schools Insurance Group (CCCSIG).       If
    your Site Administrator after EACH visit,        •    Emergency or After Hours Only         you have a question about a claim with a
    prior to your return to work.                                                               date of injury 06/30/07 or before, please
•   If you are injured on the job, your Site         1425 Main Street                           contact them at:
    Administrator Supervisor, Manager or Office      Walnut Creek 94596 (925) 295-4820          1-866-922-2744
    Manager should provide you with the
    following forms to complete and return to                                                   Christopher Torres, Ext. 220
    them:
•   State of California Workers’ Compensation        Muir Diablo Occupational Medicine          Of   course,     your    MDUSD       Workers’
    Claim Form (DWC-1)                                                                          Compensation team is here to answer your
                                                     •    2231 Galaxy Court                     questions as well. Please feel free call us at:
•   MDUSD Employee Report of Injury/Illness
    Form                                             Concord 94520 (925) 685-7744               (925) 682-8000 ext. 4163 or 4005
•   Note: If you are unable to obtain forms from
                                                     •    1981 N. Broadway
    site or department staff, please     contact
    MDUSD Workers’ Compensation at (925)             Walnut Creek 94596 (925) 932-7715
    682-8000 ext. 4163 or 4005 or find the                                                             Cut here for wallet sized card.
    forms on the MDUSD web site under                                                           ------------------------------------
    Workers’ Compensation. Once completed,                                                      MDUSD Workers’ Compensation Department
    these forms should be turned in to your Site     Emergency or After Hours Only
    Administrator/Supervisor or Manager or to        •    John Muir Medical Center              Barbara Corrick
    Workers’ Compensation located at the                                                        Workers’ Compensation Manager
    District office.                                 1601 Ygnacio Valley Rd                     (925) 682-8000 ext. 4163
•   If you have an injury at work but you choose     Walnut Creek 94598 (925) 939-3000          Martha Dreisbach
    not to seek treatment, please notify your                                                   Workers’ Compensation Assistant
    Site Administrator/Supervisor, Manager, or       •    John Muir Medical Center              (925) 682-8000 ext. 4005
    Office Manager so that we can provide you
    with the paperwork to document an incident       2540 East St.                              Our Claims Administrator:
    only report.                                                                                Claims on or after 07/01/07: TriStar
                                                     Concord 94520 (925) 682-8200
                                                                                                (925) 930-9883
                                                                                                Claims on or before 06/30/07: CCCSIG
                                                                                                1-866-922-2744