Policy Text
Page 1 of 4 26/03 (REV 4/00)
Employee Injury/Illness Reporting Requirements
The purpose of this General Order i s to define the requirements for reporting and
investigating all work related injuries and illnesses. This Gen eral Order is applicable to
all department employees including inmate workers. I. First Aid or Medi cal Treatment Only
A. First aid or medical treatm ent is any one-time treatment and any one
follow-up visit for the purpose o f observation of minor injurie s which do not
ordinarily require medical care even though the treatment and f ollow-up
may have been provided by a physi cian or other health care prof essional.
Also, the injured or ill employee must not have lost any workda ys other
than the day of the injury or onset of illness.
II. Serious Injury or Illness
A. Serious injury or illness is any incident that results in fa tality, loss of
consciousness, transfer to another job, restriction of work or motion,
and/or lost workday beyond the day of the incident. It includes any incident
which requires medical treatment beyond first aid and/or when p rescription
medication is used beyond a singl e dose administered on the fir st medical
visit. Note : A gross blood or body fluid exposure or needle stick shall be
treated as a Serious Injury/Illness.
1. A gross blood or body fluid exposure is a large amount of blood or
body fluid that makes contact wit h an employee’s intact skin or any
amount of blood or body fluid co ntacting open cuts or sores and /or
mucous membrane of an employee.
III. Required Forms for First Aid or Medical Tr eatment Only Cla ims
1. The injured or ill employee’s immediate supervisor shall pro vide the
injured/ill employee with the Stat e of California Employee’s Cl aim
for Workers’ Compensation Benefits form.
a . T h e e m p l o y e e a l s o m a y f i l e a C a s u a l t y R e p o r t to document
t h e i r i n v o l v e m e n t i n a p a r t i c u l a r i n c i dent. A copy of the
C a s u a l t y R eport shall accompany the claim package.
Page 2 of 4 26/03 (REV 4/00)
2. The employee’s immediate supervisor shall complete the fol lowing
f o r m s ( S e e S e c t i o n I V and Section V, respectively, for forms
c o m p l e t i o n and distribution instructions):
N O T E : A l l f o r m s r e f e r e n c e d i n t h i s O r d e r m a y b e a c c e s s e d o n
t h e S S D W e b , Human Resources Links , “Workers’ Comp Info &
O n L i n e F o r m s ”
a . S S D S u p e r v i s o r ’ s R e p o r t o f E m p l o y e e I n j u r y / I l l n e s s f o r m ( 7400-183 [Rev 02/00]).
b . S t a t e o f C a l i f o r n i a E m p l o y e r ’ s R e p o r t o f O c c u p a t i o n a l I n j ury
o r I l l n e s s ( F o r m 5020).
c . C ounty of Sacramento Authorizat ion for Release of Records
( W C 1 0 ) . d . F o r g r o s s b l ood exposure the supervisor also shall complete
t h e S S D P o s t E x p o s u r e C h e c k l i s t ( F o r m 7 4 0 0 - 186A-B).
e . F o r needle stick incident s, the supervisor shall complete the
S S D S h a r p s I n j u r y l o g ( F o r m 7 4 0 0 - 187) in addition to the
P o s t E x p o s u r e c h e c k l i s t . IV. Instructions for Co mpleting Required Forms
1. Employee’s Claim for Worker s’ Compensation Benefits:
a. The supervisor shall comple te lines 1 through 17 of the
“Employer” section of the form wit h the exception of line 13.
b. If the employee wants to pur sue a claim, they must complete
the “Employee” section of t he form and return it to their
supervisor. The employee sha ll use their home address on
the form.
c. Upon receipt of the complet ed form from the employee, the
supervisor must complete li ne 13 and give the employee the
pink and yellow copies of t he form. The white and goldenrod
copies shall be