Workers' Compensation Reporting Procedures
Workers' compensation is a state-mandated, employer-paid benefit for employees that sustain occupational injuries or illnesses while working for or on behalf of the University. San José State University (SJSU) employees, including faculty, special consultants, student assistants, work-study students and appointed volunteers are covered.
REPORTING PROCEDURE WHEN INJURED
1. Report the injury immediately to your Appropriate Administrator or his/her designee.
Within 24 hours, the Appropriate Administrator or his/her designee completes the employer's report form and provides a copy of the workers' compensation claim form to the employee. Fax the forms to HR at 408-924-2144. Send originals in campus mail to HR/Safety m/s 0046.
2. In case of emergency, dial 911 for paramedic assistance or (408) 924-2222 for University Police Department.
3. Seek immediate medical treatment.
- For minor injuries requiring first aid only, employees should go to Student Health Center. Call (408) 924-6120 for general information.
For medical treatment beyond first aid, employees should go to approved Occupational Medicine Facilities:
Alliance Occupational Medicine
|U.S. Healthwork San Jose
Monday – Friday
988 Walsh Avenue, Santa Clara, CA (408) 988-6868
O’Connor Hospital Emergency Room
5. For more information or questions contact the Workers’ Compensation Specialist in Human Resources at 924-2155, Sedgwick CMS the third party administrator at 510-302-3041 or the State of California Division of Workers’ Compensation Information & Assistance Unit at 1-800-736-7401
Injury Report Forms:
Employer's Report of Occupational Injury or Illness (PDF): Write a description of the accident using the employee's own account of the incident and submit to University Risk & Compliance.
Workers' Compensation Claim Form (DWC 1) and Notice of Potential Eligibility (PDF): Provide the injured employee with this form. When the employee completes and returns this form to you, forward it on to University Risk & Compliance.
For more information, see:
- Occupational Injury or Illness Reporting Policy (PDF)
- Return-to-Work Program (PDF)
- Predesignation of Personal Physician Form (PDF)
- Employee Injury Care Student Health Center Procedures (PDF)
To contact us, see Workers' Compensation.