Below are listed the Responsible Parties and the Required Actions to take.

Injured Employee

1. Immediately report job-related injury or illness to supervisor and seek appropriate medical care.
2. Request and complete Employee's Claim for Workers' Compensation Benefits (DWC Form 1).
3. Return DWC Form 1 to Supervisor or to Human Resources, Siemen's Hall 212.

Supervisor

1. Arrange for appropriate medical care.
2. Complete required forms.  Employee should fill out the DWC-1 form.
   
   • Claim Form DWC1
     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
   • Supervisor's Report of Injury
     Supervisor’s Report of Injury – MUST BE SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY
3. Fax both forms to Human Resources within 24 hours of knowledge of injury
4. Notify employee about Return-to-Work Program, maintain contact and encourage early return to work.
5. Notify Human Resources and departmental attendance clerk when employee misses work or returns to work.

Transportation of Injured Employee

Due to liability reasons, neither supervisors or fellow employee should drive an injured employee to seek treatment. If the injury is an emergency, call 911 for an ambulance. For immediate non-emergencies where an employee is unable to drive themselves to seek treatment, Humboldt has an agreement with City Cab of Eureka. Humboldt will pay City Cab for rides both to and from treatment with authorization. Please use the following form for authorization:

Human Resources

1. Complete Employer's Report for Occupational Injury or Illness (Form 5020) and send to the Third Party Administrator (TPA), along with copy of DWC Form 1 and STD 620.
2. Send copies of STD. 620 and DWC Form 1 to Environmental Health and Safety officer.
3. Return copy of DWC Form 1 to employee.
4. Send copy of Supervisor's Injury Prevention Report (STD 620) to supervisor.
5. Establish and maintain regular contact with TPA claims adjustor regarding status of claims.
6. Provide TPA with all documentation they may require to process claims. These include but are not limited to: first injury reports, doctor's statements, return to work statements, job descriptions, etc.

Environmental Health and Safety Officer

1. Investigate injury/illness if warranted, and report finding to department management and Human Resources.

Third Party Administrator (TPA)

1. Conduct further investigation to determine if work related.
2. Approve/deny claim.
3. Establish and maintain regular contact with Human Resources staff to process claims, IDL notifications and other responsibilities necessary to providing a comprehensive workers' compensation program.