Policy Text
Kern County Sheriff’s Office
Policies and Procedures
TITLE:
EMPLOYEE’S CLAIM FOR WORKER’S BENEFITS FORM
NO: N-230
APPROVED: Donny Youngblood, Sheriff-Coroner
EFFECTIVE:
September 15, 1993
REVIEWED:
11/20/2025
REVISED:
11/20/2025
UPDATED:
11/20/2025
N-230-1
POLICY
The State of California Workers’ Compensation Claim Form (DWC 1) must be given to any
employee who seeks medical treatment beyond first aid or has lost time beyond the date of
injury. The form must be provided to the employee in person or by mail within 24 hours of the
employer learning from any source of the injury/illness that resulted in medical treatment beyond
first aid or lost time beyond the date of injury.
Attached is a copy of a State of California Workers’ Compensation Claim Form (DWC 1) (Rev.
1/1/2016). The following guidelines will be used to complete the form:
“EMPLOYEE” Section, completed by injured or ill employee:
LINE #
1.
List the name of the employee submitting the claim