Reporting a Work Related Injury or Illness
Employees, Volunteers, and Student Assistants
You may be entitled to workers' compensation benefits if you are injured or become ill because of your job, or a victim of a workplace crime. Workers' compensation covers most work-related physical or mental injured. If you are injured or ill, notify your supervisor immediately.
1. Employee/Volunteer Injury/Ilness Report
For all injuries and illnesses, please complete an Employee/Volunteer Injury/Illness form . Complete and sign the "Employee" portion and return it to your manager or supervisor.
2. Employees Claim for Workers' Compensation Benefits
If an injury or illness requires more than first aid treatment, your manager or supervisor should provide you with an Employee's Claim for Workers' Compensation Benefits form . Complete and sign the "Employee" portion of this form and return it to your supervisor.
3. Seek medical treatment if needed
Prior to going for treatment or evaluation, you will need a Medical Service Order. Separate Orders are available for the main campus at Brea Urgent Care and for the Irvine Center at Saddleback Family & Urgent Care facility . You must receive the signed form from your manager or supervisor. This form lets the medical facility know that you are being seen for a work related injury or illness.
Managers and Supervisors
If an injury or illness requires medical treatment beyond first aid, you should provide the employee the following forms:
State law requires that an Employee's Claim Form be provided to an employee within 1 working day of your notice or knowledge of the work-related injury or illness. This form is available from the Total Wellness office, CP-700 extension 7346.
Immediately submit the completed and signed (1) Employee/Volunteer Injury/Illness Report, (2) Employee's Claim Form and (3) Medical Service Order (if available) to University Total Wellness (CP-700). These forms are available at the above links, or under the Forms section on the right side of this webpage. You may also call Total Wellness at 657-278-5187.