This document provides guidance for managers and supervisors on handling workplace injuries. It outlines the process for determining if an injury is urgent or an emergency and getting appropriate medical treatment. For injuries requiring time off work, it describes the steps to take, including reporting procedures, modified duty options, and obtaining doctor's releases to facilitate a safe return to work. The goal is to prioritize employee care while getting them back to productive work as soon as medically feasible.

1. Workplace Injuries
MANAGER/SUPERVISORS TRAINING

2. Workplace Injuries
As a manager or supervisor, caring for your employees is a vital
responsibility
To determine the most helpful course of action, injuries must be
prioritized and treated accordingly
There are generally two categories of workplace injuries:
◦ Urgent (First Aid)
◦ Emergency (Severe – possibly life threatening)

3. Determine Urgency
◦ Non Life-threatening (First Aid)
◦ Joint and muscle pain, sprains, aches
◦ Rash
◦ Mild to moderate abdominal pain
◦ Minor cuts
◦ Headache
◦ Ear pain
◦ Sore throat and sinus pain
◦ Cough and fever

4. Determine Urgency
◦ Serious injury (Emergency)
◦ Difficulty breathing
◦ Unconsciousness
◦ Severe bleeding from poisoning or suspected poisoning
◦ Chest pain or pressure
◦ Convulsions or seizures
◦ Serious head, neck, or back injury
◦ Loss of limb or obvious broken bone (severe)
◦ Abdominal pain with fever and/or vomiting

5. Injury Event Sequence
Doctor’s
Evaluation
Reporting
Partial
Release
Modified
Duty
Full
Release
Back to
Full Duty
Doctor’s
Evaluation
Reporting
Full
Release
Back to
Full Duty
Urgent (First Aid)
Emergency (Serious Injury with more than 3 days off work)
Depending on the severity of the injury, the sequence will follow one of
these paths to completion:

6. Workplace Injury Checklist
Determine urgency – Urgent vs. Emergency
▪ For Urgent injuries, send to Urgent Care with doctors’ release form
▪ For Emergency, send to the hospital or call 911 as needed
Get doctor’s release form completed after initial treatment
Reporting
▪ Injury Report DWC1 form within 1 business day
▪ Supervisor report – completed at same time
Modified duty
▪ Review doctors release assign duties as indicated on form
▪ Get updated release form after each follow-up doctors visit

7. Medical Treatment
Employee evaluated/treated by medical professional
Send employee with doctor release form
Doctor must complete form and give to employee to return to work
If employee is released to full duty, he/she can resume normal
responsibilities

8. TRANSITIONAL DUTY EVALUATION FORM
To Be Completed by Attending Physician
Patient’s Name (Last) (First) (M.I.)
Date of Initial Injury/Illness Date of Treatment
Brief Explanation of Diagnosis/Condition
Based on the above description of the patient’s current medical problem, I recommend the following:
Patient may return to work with no limitations On this Date:
Patient may return to work with limitations (listed
below)
On this Date:
Check all that apply as they relate to the above condition:
Sedentary Work – Lifting 10 lbs maximum
and occasionally lifting or carrying such
articles as dockets, ledgers and small tools.
Work essentially involves sitting and is
considered sedentary if only a small amount
of walking and standing is necessary to carry
out duties.
1.
In an eight hour work day, patient may:
a.
Stand/Walk
None 1-4
hours
4-6
hours
6-8 hours
b.
Sit
1-3 hours 3-5 hours 5-8 hours
c.
Drive
1-3 hours 3-5 hours 5-8 hours
Light Work – Lifting 20 lbs maximum and
frequent lifting or carrying of objects up to 10
lbs. Work is classified as light if it requires
walking or standing to a significant degree
(regardless of weight lifted) or involves sitting
most of the time with a degree of pushing
and pulling of arm or leg controls.
2.
Patient may use hand(s) for repetitive:
Single
Grasping
Fine
Manipulation Pushing/Pulling
Light-Medium Work – Lifting 30 lbs
maximum and frequent lifting or carrying of
objects weighing up to 20 lbs.
3.
Patient may use foot/feet for repetitive movement, as in
operating foot controls.
YES NO
Medium Work – Lifting 50 lbs maximum and
frequent lifting or carrying of objects weighing
up to 25 lbs.
4.
Patient may (fill in as needed):
Light-Heavy Work – Lifting 75 lbs maximum
and frequent lifting or carrying of objects
weighing up to 40 lbs.
Heavy Work – Lifting 100 lbs maximum and
frequent lifting or carrying of objects weighing
up to 50 lbs.
Other instructions and/or limitations, including prescribed medications:
These restrictions are in effect until (date): Or until patient is re-evaluated on (date):
Patient is totally incapacitated at this time, and a re-evaluation is scheduled on (date):
Referred To:
None
Private
Physician
Return
Here
A Consultant Other (specify):
Physician’s Signature Date
Patient’s Authorization to Release Information: I hereby authorize my attending physician and/or hospital to
release any information or copies thereof acquired in the course of my examination or treatment for the injury
identified above to my employer or representative.
Patient/Employee’s Signature Date

9. Reporting
As soon as practical - within 1 day of injury, complete incident report
(DWC1) and Supervisors report claim to insurance company
If any lost time will be incurred (more than 3 days) or medical costs -
report to workers compensation carrier
Call insurance agent with any questions

10. .
Rev. 1/1/2016
State of California
Department of Industrial Relations
DIVISION OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Employee: Complete the “Employee” section and give the form to your
employer. Keep a copy and mark it “Employee’s Temporary Receipt” until
you receive the signed and dated copy from your employer. You may call the
Division of Workers’ Compensation and hear recorded information at (800)
736-7401. An explanation of workers' compensation benefits is included in
the Notice of Potential Eligibility, which is the cover sheet of this form.
Detach and save this notice for future reference.
You should also have received a pamphlet from your employer describing
workers’ compensation benefits and the procedures to obtain them. You may
receive written notices from your employer or its claims administrator about
your claim. If your claims administrator offers to send you notices
electronically, and you agree to receive these notices only by email, please
provide your email address below and check the appropriate box. If you later
decide you want to receive the notices by mail, you must inform your
employer in writing.
Empleado: Complete la sección “Empleado” y entregue la forma a su
empleador. Quédese con la copia designada “Recibo Temporal del
Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736-
7401 para oir información gravada. Una explicación de los beneficios de
compensación de trabajadores está incluido en la Notificación de Posible
Elegibilidad, que es la hoja de portada de esta forma. Separe y guarde esta
notificación como referencia para el futuro.
Ud. también debería haber recibido de su empleador un folleto describiendo
los benficios de compensación al trabajador lesionado y los procedimientos
para obtenerlos. Es posible que reciba notificaciones escritas de su
empleador o de su administrador de reclamos sobre su reclamo. Si su
administrador de reclamos ofrece enviarle notificaciones electrónicamente, y
usted acepta recibir estas notificaciones solo por correo electrónico, por
favor proporcione su dirección de correo electrónico abajo y marque la caja
apropiada. Si usted decide después que quiere recibir las notificaciones por
correo, usted debe de informar a su empleador por escrito.
Any person who makes or causes to be made any knowingly false or
fraudulent material statement or material representation for the
purpose of obtaining or denying workers’ compensation benefits or
payments is guilty of a felony.
Toda aquella persona que a propósito haga o cause que se produzca
cualquier declaración o representación material falsa o fraudulenta con
el fin de obtener o negar beneficios o pagos de compensación a
trabajadores lesionados es culpable de un crimen mayor “felonia”.
Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba.
1. Name. Nombre. ___________________________________________________ Today’s Date. Fecha de Hoy. ____________________________________________
2. Home Address. Dirección Residencial. _____________________________________________________________________________________________________
3. City. Ciudad. _______________________________________ State. Estado. _____________________ Zip. Código Postal. ______________________________
4. Date of Injury. Fecha de la lesión (accidente). ________________________________ Time of Injury. Hora en que ocurrió. ____________a.m. ___________p.m.
5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _______________________________________________________
_______________________________________________________________________________________________________________________________________
6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7. Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________________________
8.  Check if you agree to receive notices about your claim by email only.  Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo
electrónico. Employee’s e-mail. _____________________________________ Correo electrónico del empleado. __________________________________________.
You will receive benefit notices by regular mail if you do not choose, or your claims administrator does not offer, an electronic service option. Usted recibirá
notificaciones de beneficios por correo ordinario si usted no escoge, o su administrador de reclamos no le ofrece, una opción de servicio electrónico.
9. Signature of employee. Firma del empleado. ________________________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
10. Name of employer. Nombre del empleador. ________________________________________________________________________________________________
11. Address. Dirección. __________________________________________________________________________________________________________________
12. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. ___________________________________________
13. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ______________________________________________________
14. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador._____________________________________________________
15. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. _______________
_______________________________________________________________________________________________________________________________________
16. Insurance Policy Number. El número de la póliza de Seguro.___________________________________________________________________________________
17. Signature of employer representative. Firma del representante del empleador. ____________________________________________________________________
18. Title. Título. _________________________________________ 19. Telephone. Teléfono. ___________________________________________________________
Employer: You are required to date this form and provide copies to your insurer
or claims administrator and to the employee, dependent or representative who
filed the claim within one working day of receipt of the form from the employee.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su
compañía de seguros, administrador de reclamos, o dependiente/representante de
reclamos y al empleado que hayan presentado esta petición dentro del plazo de
un día hábil desde el momento de haber sido recibida la forma del empleado.
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado
PRINT CLEAR

11. Return To Work
In the case of a partial release from the treating physician, the
employee should work his/her normal hours at normal pay with duty
restrictions based on the doctors instructions
Use established list of tasks being cautious to work within the doctor’s
instructions
For example, no lifting objects overhead, no more than 10 lbs., etc.

12. Modified Duty
Example Modified Duty Options
Type of Injury
Back Lower Upper
Workplace training Yes Yes Yes
Research / analysis / survey Yes Yes Yes
Administrative work Yes Yes Yes
Safety inspection Yes Yes Yes
Delivery Maybe Maybe Yes
Routine maintenance Maybe Maybe Maybe
Marketing Yes Yes Yes
Sales Yes Yes Yes
Equipment inspection Yes Yes Yes

13. Keep Employees Working
Getting the employee – even on a modified basis – is extremely
beneficial to the employee and the company
Employees who return to work on modified duty typically make quicker
and more complete recoveries than those who do not
Get a list of modified duties and have a formal return to work policy in
place to keep the process moving forward
Continue to monitor the progress and obtain updated doctor’s release
forms until the injury is resolved (full release from doctor)
Document the employees file and update workers comp claims case
manager as situation develops