Policy Text
Kern County Sheriff’s Office
Policies and Procedures
TITLE:
REQUEST FOR MEDICAL INDUSTRIAL INJURY FORM
NO: N-240
APPROVED:
Donny Youngblood, Sheriff-Coroner
EFFECTIVE:
September 15, 1993
REVIEWED:
05/11/2018
REVISED:
03/01/2007
UPDATED:
05/11/2018
N-240-1
POLICY
The REQUEST FOR MEDICAL SERVICE - INDUSTRIAL INJURY form is used to notify an
employee of the medical facilities where they may seek medical treatment due to a work-related
injury or illness. The form also authorizes a physician to render immediate medical treatment to
the employee. The injured employee is not authorized to complete this form.
Attached is a copy of the REQUEST FOR MEDICAL TREATMENT - INDUSTRIAL INJURY
form (requestmedical.doc (revised 1/18/07). Do not make recommendations as to which doctor
the employee should see. The providers listed on the REQUEST FOR MEDICAL
TREATMENT-INDUSTRIAL INJURY form are under contract to the County and a
recommendation of one provider could be d