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Reporting An Injury

Reporting An Injury

Step #1: Get Medical AttentionEmployees should obtain medical treatment at OHF for non-emergencies that occur during normal business hours, or the RRMC/SMUCLA Emergency Department for emergencies and/or off-hours treatment. See below for additional information:

Step #2: Complete Necessary Forms

1. UCLA Health Incident Report & Referral for Medical Treatment Form

    • Required as a record that an injury or illness was reported
    • Take the completed form to OHF/ER
      Your medical provider will describe your received treatment and any work restrictions or future appointments
      Be sure to return the form to your supervisor after treatment

2. Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
      Must be provided by a supervisor within 24 hours of the report of injury or illness

Step #3: Report the Injury to HR/Workers' Compensation

1. If the injury is Serious Injury, page The Office of Environmental Health & Safety (EH&S) IMMEDIATELY (Pager: 90248)

   Provide the necessary information when reporting a serious injury:  

  • Employee name, title and department
  • Supervisor name and phone
  • Your name, title, department and contact information
  • Date, time and location of incident
  • Description of what happened
  • Whether or not employee got medical treatment and, if so, where

Serious injury includes:
     Amputation
     Concussion
     Injury resulting in serious degree of permanent disfigurement such as crushing injury or severe burn
     In-patient hospitalization in excess of 24 hours for other than medical observation

*If serious injuries are not reported within 8 hours, departments can be fined $5,000.00 by Cal/OSHA.
Download a copy of the Serious Injury Poster (PDF). 

2. Contact HR/Workers' Compensation within 24 hours for ALL injuries

A. FAX a copy of the completed form to the WC FAX line: Health System HR (310) 794-3337 or
B. EMAIL to
hrworkerscomp@mednet.ucla.edu or
C. CALL 877-6UC-RPRT (877-682-7778) with the information on the forms

  • Report all injuries (serious and non-serious) to HR/Workers' Compensation within 24 hours

 

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