***If medical treatment is required, please see our section on Medical Treatment Authorization and Facilities, and immediately contact the Workers’ Compensation Office at 805-893-8050.***

INSTRUCTIONS

With notification of an illness or incident, it is the responsibility of the supervisor to complete and immediately submit the Incident Report form to the Workers’ Compensation Office:

The employee and supervisor are responsible for completing the Incident Report form.

• If the supervisor is unavailable to complete the Incident Report, the employee should complete the form.

• If the employee is unable to complete the Report, it is the supervisor’s responsibility to complete it for the employee.

• The Incident Report must be completed within 24 hours of the University’s first notice of incident.

• FAX THE COMPLETED FORM IMMEDIATELY TO THE WORKERS’ COMPENSATION OFFICE AT 805-893-8521. Give a copy to the employee, and retain a copy for your department file.

All questions on this form must be answered before it can be processed.

Click here to download the form in a modifiable PDF format.

FURTHER INFORMATION

If the employee’s injury or illness is medically determined to meet the State of California definition of injury as a workers’ compensation claim, the Workers’ Compensation Office will mail the employee a Workers’ Compensation Claim Form (DWC-1). The employee completes and signs the Employee section of the form and returns it to the Workers’ Compensation Office at Mail Code 2090. The Workers’ Compensation Office will complete the Employer section of the form and send a final copy back to the employee. If the supervisor receives a claim form from an employee, the supervisor should forward the form to the Workers’ Compensation Office for completion.

Sedgwick CMS (Claims Management Services) has a contract with the University of California to administer Workers' Compensation claims filed by University employees. A Sedgwick CMS claims administrator will discuss the claim with the employee, investigate the injury, and determine acceptance of the claim.

Reporting an injury or submission of a claim form does not imply automatic approval of the claim. Claims are approved by Sedgwick CMS for UCSB.

If a representative from Sedgwick CMS contacts you, please provide any information requested. This includes departmental files, job description, or time records.

Please contact the Workers’ Compensation Office at 805-893-8050 for further information.

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