Workers' Compensation
Checklist for Supervisors

Action

When there is an injury:

1. Refer the employee to Employee Health Services (EHS) at 2380 Sutter Street, 3 rd Floor. If the injury occurs during clinic hours (7:30 AM to 4:00 PM) call 885-7580 to make an appointment. If the injury occurs after hours, the injured should go to the Long Hospital emergency department.
   
   
2. If applicable, remove, tag and store any broken equipment that caused the injury. Note: do not discard equipment or furnishing that has caused the injury.
   
   
3. Notify OHRS
   
   
4. Complete the Supervisor' Report of Employee Injury (SRI) form.
   
   
5. Fax the form to Disability Management Services 476-2328
   
   
6. Mail the original form to Disability Management Services at Box 0964.

If it appears that the employee may lose time from work beyond the day of injury, the Supervisor should prepare and sign an RPA with the requested leave start and end-dates and send it to OHRS.

The Supervisor is responsible for preparing and submitting the employee's timesheet during the leave.

When the employee is ready to return to work, he/she should contact his/her Supervisor to make arrangements for his/her return.

The employee must provide the Supervisor with either a FMLA return to work certification or a note of release to work from his/her physician.

The supervisor should prepare, sign and send an RPA to OHRS (along with the return to work certification or note from the physician if applicable.)