500.21 work related accidents

1. COUNTY OF ORANGE
HEALTH CARE AGENCY
REGULATORY HEALTH SERVICES
ANIMAL CARE SERVICES
Number: 500.21
SUBJECT: EMPLOYEE INJURY AND ILLNESS Page: 1
Date: 11/09/79
Approved: Jennifer Phillips, Director Revised: 11/14/06
I. PURPOSE
To establish a uniform procedure for reporting employee injuries.
II. POLICY
Any employee who is injured in the performance of his or her duties shall immediately report
the incident to a supervisor.
The supervisor shall initiate all required forms and ensure that the employee receives
immediate and appropriate medical care.
III. SCOPE
Applicable to all Orange County Animal Care Services (OCACS) personnel.
IV. FORMS
Employer's Report of Occupational Injury or Illness (Form 5O2O)
Supervisor’s Investigation of Employee’s Injury or Illness (F293-Form Safety.2)
Division of Worker’s Compensation (DWC Form 1)
Employer’s Authorization for Examination or Treatment
V. REFERENCES
CEO/Risk Management Intranet “Employee Injury and Illness Instructions/Forms Packet”
VI. DEFINITIONS
Not applicable.
VII. PROCEDURE
A. Employee’s Responsibilities:
1. Report the work related injury to a supervisor immediately or as soon as
possible. All work related injuries must be reported prior to the end of the
working day.

2. COUNTY OF ORANGE
HEALTH CARE AGENCY
REGULATORY HEALTH SERVICES
ANIMAL CARE SERVICES
Number: 500.21
SUBJECT: EMPLOYEE INJURY AND ILLNESS Page: 2
Date: 11/09/79
Approved: Jennifer Phillips, Director Revised: 11/14/06
2. If requesting treatment:
a. Supervisor will complete the required forms and direct employee to the
approved medical facility.
b. If necessary, a Field Services supervisor will meet or transport the
employee at the medical facility and complete the required forms.
3. If declining treatment on day of injury:
a. Injury must still be reported to a supervisor before the end of the
scheduled work day, and the Employer’s Report of Occupational Injury
or Illness form (5020) shall be completed.
b. In section 27 of the Employer's Report of Occupation Injury, employee
must state in writing that he or she is declining treatment at this time.
Sign and date the form.
NOTE: Treatment for this injury may be received at a later date.
B. Supervisor's Responsibilities:
1. Ensure that all forms are completed as required.
2. When applicable, direct or transport injured employee to nearest approved
medical center.
3. Forward completed forms to OCACS Staff Assistant.
4. If employee declines treatment at this time, ensure that he or she writes and
signs their request in section 27 of the Employer’s Report of Occupational
Injury or Illness form.
5. If the employee will be off duty due to the injury, fax (714) 834-4445 medical
report to Human resources.
6. All time-off requested on employee’s scheduled workday for follow-up medical
treatment will be deducted from the employee’s annual leave balance.
7. In case of hospitalization or death, a supervisor must immediately contact the
Director of OCACS, and the County Safety Officer (714) 834-3075. For after
hours, contact the Safety Officer at Control I at (714) 628-7008.