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Alameda County, CA, acgov.org

Workers' Compensation

  • FORM 5020 (PDF - 558kb)*: State of California EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS. This form must be completed within 5 days of knowledge of an injury or illness.
  • DWC1 FORM (PDF - 148kb)*: Complete this form if your physician indicates that your injury requires medical treatment beyond first aid or certifies disability beyond your work shift at the time of your injury. Complete the employee section of this form and return the completed form to your supervisor.
  • SUPERVISOR’S INVESTIGATION OF EMPLOYEE INJURY (PDF - 84kb)*: This form must be completed by supervisor when obtaining information from the injured employee.
  • WITNESS TO A JOB RELATED INJURY (PDF - 18kb)*: This form must be completed by any and all witness to a job related injury.
  • PRE-DESIGNATION OF TREATING PHYSICIAN FORM (PDF - 149kb)*: Before an injury, use this form to notify the County if you wish to have your personal medical doctor treat you for a work-related injury or illness and the requirements are met.
  • NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST FORM (PDF - 176kb)*: This is a form that the employee can use to change treating physician to their personal chiropractor or acupuncturist within the first 30 days of treatment following a work-related injury or illness.
  • FIRST FILL PHARMACY FORM (PDF - 129kb)*: Give this notice to any pharmacy listed on the form to expedite the processing of your prescriptions.
  • WORK STATUS REPORT (PDF - 82kb)*: Bring this form to each medical appointment. Your medical provider must complete at every appointment, and you must provide a copy to your supervisor/WCL.
  • EFJA/EF5 (PDF - 473kb)*: The EF5 form is intended to describe the employee’s essential job functions. These are identified as those duties that are required to accomplish the purpose of the job for which the employee was hired. This form is to be completed when requested by the claims adjuster to determine the injured employee’s ability to return to work. Your claims adjuster can identify resources to assist you in completing the form.

* Portable Document Format (PDF) file requires the free Adobe Reader.

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