Before an Incident Occurs
This form is to be completed if you wish to designate your physician to treat you in the event of a work related injury or illness. You must submit this form to ÐÓ°ÉרÇø Human Resources before a work related injury or illness occurs.
After an Incident Occurs
The purpose of this guide is to help supervisors and managers understand the workers’ compensation process at ÐÓ°ÉרÇø, Inc. when an employee becomes ill or injured.
The purpose of this guide is to help employees understand the workers’ compensation process at ÐÓ°ÉרÇø, Inc. and to become familiar with the procedures required when a work-related injury or illness occurs.
Flier on what to do when a ÐÓ°ÉרÇø employee working on the Sacramento State campus has a work-related injury or illness on the job.
Instructions for reporting a work related injury/illness for both emergency and non-emergency situations.
Accident Report – Work Related Injury/Illness
This form represents both the original notification of work-related injury/illness and detailed report of the injury/illness. This form is to be completed by the supervisor and employee within 24 hours of injury/illness.
This form is to be completed by the employee and ÐÓ°ÉרÇø Human Resources or employer representative (i.e. supervisor) for work related injury/illness that results in lost time beyond the date of injury/illness or which results in medical treatment beyond first aid.
Requirements for the supervisor when an employee is returning to work following a work related injury/illness.
Treatment Resources
Group of health care providers in the Sacramento area set up to treat ÐÓ°ÉרÇø employees injured on the job.
A list of Kaiser occupational health center locations and contact phone number for ÐÓ°ÉרÇø employees who do not live or work in the Sacramento area. These centers are set up to treat ÐÓ°ÉרÇø employees injured or became ill on the job.
This form authorizes Kaiser Health Center to provide a ÐÓ°ÉרÇø employee treatment for a work related injury/Illness. Contact ÐÓ°ÉרÇø Human for authorization signature. Please call ahead for on the job injury/illness care to ensure timely treatment.
Release of Information Forms
Concentra Authorization for Examination or Treatment Form
This form authorizes Concentra Clinic (formerly U.S. HealthWorks) to provide a ÐÓ°ÉרÇø Employee treatment for a work related injury/Illness. Contact ÐÓ°ÉרÇø Human Resources for authorization signature. Please call ahead for on the job injury/illness care to ensure timely treatment.
If treated for a work related injury/Illness at the Student Health and Counseling Services (SHCS), this form authorizes the SHCS to disclose/exchange information contained in your medical record between SHCS and ÐÓ°ÉרÇø Human Resources for your work status (i.e. Off full duty or restricted duty).  Contact ÐÓ°ÉרÇø Human Resources for authorization signature.