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Step #1: Notification

• Inform your supervisor immediately if you sustain a work-related injury or illness.

Step #2: Medical Authorization:

• Your supervisor will complete and provide you with this form for non-emergency medical care and will refer you to the University's designated industrial medical clinic for further evaluation and treatment.
• If you have a current Personal Physician Pre-Designation Form on file with Æðµã´«Ã½'s Workers’ Compensation Office, you may seek evaluation and treatment for your work-related injury or illness from your personal physician. Please note that the pre-designation form must have been submitted prior to the date of injury or illness and must include your physician’s agreement to provide treatment for work-related injuries and illnesses. To verify whether a current pre-designation form is on file, please contact the Workers’ Compensation Office by email or at 909-869-3725

Step #3: Reporting Forms

• Manager's Report of Injury/Illness Form: Work with your manager to complete this form.

• Workers' Compensation Claim Form (DWC1): If a work-related injury or illness requires more than first aid treatment, your manager or supervisor should provide you with a Workers' Compensation Claim Form. Complete and sign the employee portion of this form as it initiates the claim process and protects your rights.

Workplace Injury & Illness 3 Step Guide Response guide

• Medical Authorization Form

• Personal Physician Pre-Designation Form

• Manager's Report of Injury/Illness Form

• Workers' Compensation Claim Form (DWC1)

Submit forms via one of the following methods within 24 hours:

•  (an OnBase/PolyDoc form)

• Sealed inter-office mail (marked as Confidential)

• Drop off the form in-person with the HR Customer Service Center in the Student Services Building 121, Second Floor

Do not email or fax any documents that contain Social Security numbers or any other personally identifiable information. 

View the Pharmacy Locator, Refill-Too-Soon, and Home Delivery Guide from Optum to provide helpful information.

Sedgwick CMS
CSU Unit
PO Box 14629
Lexington, KY 40512-4629
Phone: (916)636-1500
Fax: (916) 851-8089

Injured Employee Returning to Work Without Restrictions

If an employee is released to return to work without restrictions, the employee must obtain a written full-duty release from the treating physician and submit it to the Workers’ Compensation Office upon returning to work immediately. The release may be provided via email, fax, or the Secure Submission Form.

The Workers’ Compensation Office will notify the employee’s supervisor regarding the employee’s work status.

Employees may not return to work without a written release from the treating physician. Supervisors should not permit an employee to return to work until the appropriate release has been received and reviewed.

Injured Employee Returning to Work With Restrictions

If the physician releases you to modified-duty or light-duty work, your manager and the Workers’ Compensation Office will review the work restrictions and work with your department to determine whether the temporary work restrictions can be honored.

If the department is able to honor the temporary work restrictions, your supervisor and the Workers’ Compensation Office will meet with you to discuss the temporary duties and review the work restrictions prescribed by the physician.

The temporary duties will be reviewed at regular intervals to ensure that you continue to recover and progress toward returning to your regular duties. Modifications to the temporary duties will be made as appropriate.

If the department is unable to honor the temporary work restrictions, a Workers’ Compensation staff member will contact you to discuss the available options.

Employees in need of an ADA reasonable accommodation should contact the ADA Office and begin the ADA reasonable accommodation process.

Return to Work Process