Workers� Compensation Forms Information by Klipart

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									                     Workers’ Compensation Forms Information
                           Need Help? Call Risk Management at (650) 723-7400

General Instructions For Completing Forms


SU-17 is completed for any on campus injury or illness involving a Stanford University
   employee, student, visitor, contractor, etc. This form must be processed within 24 hours
   and faxed as directed on form.

    There are different forms for employees and student employees versus visitors, students,
    and other third-parties. These forms are available at
    http://www.stanford.edu/dept/Risk-management/docs/workcompben.shtml

State Form DWC-1 is completed for work-related injury or illness when one or more
   workdays is lost or when treatment is required by a physician in a medical facility. This
   form must be provided to employee within 24 hours. This form is available at
   http://www.stanford.edu/dept/Risk-Management/docs/workcompben.shtml
   and also from Risk Management, phone 723-7400. Make photocopies as needed. Submit
   the original and one copy to Risk Management, mail code 6207.

CAL OSHA 5020 is completed by the department for employees when one or more workdays
  are lost or when treatment is required by a physician in a medical facility. The State does
  not allow the injured employee to complete this form. This form is available at
  http://www.stanford.edu/dept/Risk-Management/docs/workcompben.shtml
  This form must be typed and may be done in MSWord by downloading the “PC Word
  Version” from the above website. Submit original to Risk Management, mail code 6207.

SU-16 is completed when an employee, who has lost one or more full days of work or had
   restricted work activity due to a work-related injury or illness, returns to work, or is off
   restrictions. This form is available at:
   http://www.stanford.edu/dept/Risk-Management/docs/workcompben.shtml
   and is submitted on-line to Risk Management.

Employee Personal Physician Pre-designation Form may be completed and submitted by an
  employee before an injury occurs. Their personal physician must have treated them and
  maintained their medical history and records before their work injury. If an employee does
  so, they may see him or her for treatment. This is the doctor with overall responsibility for
  treating their injury or illness. If they wish to change doctors in the first 30 days, Stanford’s
  claims administrator must select a new physician within five days of their request. (If they
  gave Stanford the name of their personal chiropractor or acupuncturist in writing before
  they were injured, they may switch to the chiropractor or acupuncturist upon request.)
  If they are filing a claim for work-related mental stress or psychiatric disability, please have
  them contact their personal physician for a referral even if they have not completed an
  Employee Personal Physician Pre-designation Form.




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Checklist To Avoid Most Frequent Errors
Follow “General Instructions For Completing Forms” and then check for the following:


SU-17
        Download a fresh form each time
        Mark appropriate boxes in upper right-hand corner under “Employee Group.”
        Employee Section Part 1 – enter full department name (no abbreviations)
        Employee Section Part 1 – indicate whether Bargaining Unit (Yes or No)
        Second page – print Employee’s name at top of page
        Supervisor Section Part 3 – if Sharps Injury, provide the “If yes” information
        Fax within 24 hours as directed on form

State Form DWC-1
        Download a fresh form each time.
        Make photocopies. Send original and one copy to Risk Management, mail code 6207
        Line 1 – department fills in only the name of the employee
        Line 8 – have the employee provide full phone number including area code
        Lines 11, 12 – fill in dates before giving to employee
        Line 13 – fill in date after employee has signed and returned form
        Line 16 – sign by employer representative
        Line 18 – enter full phone number including area code

CAL OSHA 5020
        Download a fresh form each time
        The injured employee is not permitted by the State to complete this form. It must be completed
         by the department
        All phone numbers - enter full phone number including area code
        Box 14C – enter full name of department (no abbreviations)
        Box 21 – if employee is unable to return to work after the day of the injury/illness, mark the
         “yes” box. If employee is able to return to work, mark the “no” box
        Box 28 – enter date the DWC-1 was given or mailed to the employee

SU-16
        Fill out after employee returns or is off restricted work activity
        Fill out each time an employee returns or is off restricted work activity
        Date of Injury – always enter the original date of injury
        Total Lost Days or Total Restricted Days – enter the number of all calendar days on which the
         employee could not work because of occupational injury/illness or was on restricted work. All
         calendar days include weekends and holidays during lost time. (These instructions are on the
         SU-16 form but are often overlooked.)
        Total Lost Days or Total Restricted Days – once the 180-day limit is reached, enter “180
         maximum.” This maximum is reached when the total or combination of both reaches 180 days
        End of calendar year – if they have not returned to work or off restrictions by 12/31, then a SU-
         16 must be submitted for the days in the current year. Enter “continuing” in the “Date Returned
         to Work” field. Once they have returned or off restrictions in the new year, submit a SU-16
         again with only the new year’s days entered. Enter the date returned in the “Date Returned to
         Work” field. Always use the original date of injury
        Click the “Submit” button to transmit to Risk Management. No paper copy needed




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