Human Resources » Injured at Work?

Injured at Work?

A school district, being a dynamic environment, sometimes experiences accidents to employees. Should you experience a work related injury, please contact your supervisor immediately to fill out the appropriate forms. 

Employee's instructions in the event of a workplace injury: 

Employee should immediately contact Company Nurse Hotline at 1-888-770-0929, or if the employee is in need of immediate medical treatment, call 911.

Employee receives and completes the following information and forms:

**Receipt of Workers’ Compensation Information form

**Workers’ Compensation Injury Report form 

**DWC-1 Claim Form (Employee section numbers 1 thru 9 only)

  Mitchell ScriptAdvisor First Fill - Temporary Prescription Card (effective 2/1/2017)

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish

**Employee must have contacted the Company Nurse Hotline and completed these 3-forms to initiate a claim. Please return all completed forms to your immediate supervisor, and/or send to Dinah Barajas in the ESUSD Office of Human Resource (email: dbarajas@esusd.k12.ca.us or FAX: 310-322-0231).

 

Supervisor's instructions in the event of a workplace injury:  

Supervisor must provide employee with the required forms and informational pamphlets noted above as soon as they are aware of the injury.  

Please ensure the employee has contacted the Company Nurse Hotline at 1-888-770-0929

Supervisor must complete and return the Supervisor Report of Injury form to the ESUSD Office of Human Resources along with the employee's required forms noted above.  

 
COMPLETE INSTRUCTION & FORM PACKET: For your convenience, a packet with both the supervisor and employee required forms and information can be downloaded here.

 

MANDATORY WORKPLACE WORKERS' COMPENSATION POSTERS/FLYERS:  Please post the following on all staff information bulletin boards or common areas.

DWC - 7 Notice to Employees--Injuries caused by Work (CA DIR):  Post in English and Spanish

Workers' Compensation Fraud:  Post in English and Spanish

Company Nurse Hotline Flyer

U.S. Healthworks Urgent Care (First Care Provider) Flyer 

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish