INJURY CHECK LIST: A detailed document checklist that will ensure you do not miss a step in properly filing a Workers' Compensation Claim.
FACTS FOR INJURED WORKERS: : This is a pamphlet that explains who is covered for workers’ compensation benefits, when they are covered for workers’ compensation benefits, and what benefits are proved through the Workers’ Compensation system. It also explains other programs unique to the County of Riverside and County of Riverside employees.
EMERGENCY SITUATIONS: Procedures designed to assist a supervisor through emergency situations.
MEDICAL SERVICE ORDER / DECLINATION STATEMENT: This form should ALWAYS be sent with the injured worker when they are being sent for treatment to an industrial clinic. This form can also be used by the employee to decline medical treatment. This form is required in triplicate. Please call the Workers' Compensation Division for a supply [951-955-5864]. How do I fill out the Medical Service Order?
ACKNOWLEDGEMENT FORM [WC35]: This form is given to an injured employee and it acknowledges their receipt of the Employee Claim Form DWC-1 and of the Facts for Injured Workers' Pamphlet. How do I fill our the Acknowledgement Form?
SUPERVISOR'S REPORT OF EMPLOYEE INJURY: [SAFETY FORM 674]: This is a safety form that can be obtained directly from the Human Resources, Safety Web Site. How do I fill out the Supervisor's Report of Employee Injury?
EMPLOYERS FIRST REPORT [FORM 5020]: This is a form filled out by the Supervisor/Manager via the Call Intake Center at 1-888-826-7835. This Form SHOULD NEVER BE FILLED OUT BY HAND. It is a CONFIDENTIAL Form. This means only the Supervisor/Manager (via the Call Intake Center) and the Workers' Compensation Division should have access to this form. How do I fill out the 5020?
EMPLOYEE CLAIM FORM [DWC-1]: This form should be provided to an employee when the injury is reported, or within 24 hours of when the injury is reported. This form is a multi-copy form. PLEASE make every attempt to utilize the pre-printed form. If you need copies of this form call the Workers' Compensation Division. If you must use the web form, please note the multi-copy requirements and how they must be distributed.
GUIDEBOOK FOR INJURED WORKERS: This is the State's Guidebook to help injured workers understand the status of their workers' compensation benefits and what actions are being taken on their workers' compensation claim.
RETURN-TO-WORK REFERRAL FORM: The County of Riverside is committed to returning employees to work as soon as possible. For this reason we have created the Return to Work program to coordinate physician opinions with employment/work opportunities. If the physician finds the employee can return to work in a modified or alternate capacity, please fill out this form and send it to the Return to Work Coordinator in the Workers’ Compensation Division.