Predesignation of a Personal Physician
Due to COVID-19 and the implementation of social distancing, we ask that all Workers' Compensation claim forms and documents be scanned and emailed to Michelle Caisse (mca33@humboldt.edu) 707-826-4501, if possible. If you are unable to submit the forms in this way, please email Michelle with details of the claim so we are able to report claims within the legal timeframe.
It is the policy of Cal Poly Humboldt to:
- Provide a safe and healthful work environment for all employees.
- Ensure that employees that are injured or become ill on the job receive appropriate medical attention.
- Return employees who have received disabling injuries to full or modified work as soon as their medical conditions permit.
- Not discriminate against workers who are injured in the course and scope of their employment.
Employees of the Cal Poly Humboldt are covered for any injury/illness arising out of or in the course of employment, at no charge to the employee. Sedgwick CMS Services is the plan administrator for workers' compensation.
All job-related injuries or illnesses should be immediately reported to the employee's supervisor or Human Resources. Employees will be given an "Employee's Claim for Workers' Compensation Benefits" form to complete and return to Human Resources.
If emergency care is required, employees should seek services from Mad River Emergency Room or St. Joseph's Emergency Room. For non-emergency care, employees must contact Mad River Occupational Health Services to provide medical treatment for the first 30 days from the date of injury. However, if prior to an injury, Human Resources has been provided with a Pre-Designation Form signed by a personal physician, employees may seek medical care from this physician immediately after injury. Under Labor Code Section 4600 (d) the designated physician must (1) be the employee's primary care physician, (2) have treated the employee in the past, (3) retain his or her medical records (including medical history), and (4) agree to be predesignated.
If an employee qualifies for workers' compensation, all approved medical bills will be paid in addition to any temporary or permanent disability payments to which an employee is entitled.
If an employee is unable to work as a result of a work-related injury or illness, he or she may elect to receive Industrial Disability Leave (IDL) in lieu of temporary disability payments. IDL provides full pay for the first 22 days of disability, with two-thirds pay for the next 11 months of disability. Employees disabled for 14 days or less do not receive IDL for the first three days (waiting period) unless hospitalized.
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For injuries requiring and not requiring medical treatment
Workers’ Compensation Forms
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Employee’s Report of Injury (DWC-1) – Must be given to employee at the time injury is reported to Supervisor, or as soon as possible after medical treatment is received
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Supervisor’s Report of Injury – MUST BE SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY
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The document includes links to all the necessary forms for the Workers' Compensation process.
St. Joseph's Occupational Health Care is no longer available for non-emergency treatment.
**DO NOT EMAIL DOCUMENTS WITH SSN's ON THEM!**
Additional Resources
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Industrial Disability Leave Administrative Guide
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Predesignation of a Personal Physician
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The Division of Workers' Compensation (DWC) monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits.
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