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Alameda County, CA, acgov.org

Reporting an Industrial Injury

IF CASE OF MEDICAL EMERGENCY, CALL 9-1-1.

If necessary, go directly to the emergency room

NEW!!! Effective July 1, 2013, Alameda County is switching to York Risk Services Group as its Workers' Compensation TPA and implementing a nurse-staffed injury hotline to report industrial injuries and initiate the filing of a workers' compensation claim. Our new claims system is paperless.

The employee will still need to complete (and sign) a DWC-1 and return it to the supervisor, for scanning and e-mailing to the TPA.

The Form 5020 will be generated from the telephonic report, and a link to the nearly completed electronic form sent to the departmental workers' compensation liaison for review, completion of a few fields, and electronic submission.

We encourage all departments to use this new, sustainable process.

In cases where it is not possible to report the injury through the hotline, forms still may be completed by hand and scanned or faxed to the new TPA.

IF NOT A MEDICAL EMERGENCY, EMPLOYEE SHOULD CONTACT SUPERVISOR IMMEDIATELY AND
FOLLOW THE PROCESS BELOW.

image of company Nurse
  1. Supervisor (with injured employee) immediately calls Company Nurse BEFORE injured employee seeks treatment.
  2. Company Nurse gathers information over the phone and either recommends first aid or refers employee to appropriate medical treatment at a designated facility or pre-designated physician.
  3. Company Nurse will alert medical facility that employee will be coming for treatment.
  4. If medical treatment is beyond first aid, supervisor gives employee the DWC-1. Employee completes employee sections of the form and returns it to the supervisor. Supervisor completes employer sections and scans and e-mails to TPA.
  5. Employee obtains appropriate medical care promptly at the designated facility or pre-designated physician as set forth in Labor Code section 4600(d) (1)-(d) (2).

Injured employees who initially receive only first aid treatment may call Company Nurse again if they need a referral or symptoms worsen. Company Nurse is NOT a substitute for medical treatment.

More Information on how the Company Nurse Injury Hotline works.

  • Company Nurse EZ Reference Guide (PDF - 258kb)*: This describes the injury reporting process effective July 1, 2013. If the supervisor reports the injury to Company Nurse, York will partially complete a Form 5020 and notify the workers' compensation liaison (WCL) when the form is ready for the WCL to review, complete the remaining fields and submit.
  • Company Nurse Injury Reporting Flow Chart (PDF - 109kb)*: Describes the information flow from the initial call to Company Nurse to the provision of medical treatment to creation of the workers' compensation claim.
  • Sample Company Nurse Report of Injury (PDF - 26kb)*: Here is a sample of the report that is created by Company Nurse when the supervisor and employee call t report an injury.
  • Company Nurse FAQ's (PDF - 112kb)*: These FAQ's provide additional information on the Company Nurse Injury hotline
  • DESIGNATED PHYSICIAN AND MEDICAL FACILITY (PDF - 179kb)*: For non-emergency treatment, Company Nurse will direct the employee to go to an approved occupational health facility, unless they have pre-designated a physician prior to an injury. Even with a pre-designated provider, an employee may either go to that provider or an approved occupational health facility.

Forms you may need:

  • DWC1 FORM (PDF - 148kb)*: Supervisor provides this form to employee within 24 hours of notice of injury requiring medical treatment beyond first aid or if physician certifies disability beyond the employees work shift at the time of the injury. ONLY THE EMPLOYEE MAY COMPLETE THE EMPLOYEE SECTION. Supervisor completes the employer section and submits to WCL/TPA.
  • FIRST FILL PHARMACY FORM (PDF - 437kb)*: Give this notice to any pharmacy listed on the form to expedite the processing of your prescriptions.
  • FORM 5020 (PDF - 201kb)*: State of California EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS. Supervisors only need to complete a hard copy of this form if they have NOT reported the injury to Company Nurse or entered the form online.
  • SUPERVISOR'S INVESTIGATION OF EMPLOYEE INJURY (PDF - 367kb)*: This form must be completed by supervisor when obtaining information from the injured employee.
  • WITNESS TO A JOB RELATED INJURY (PDF - 12kb)*: This form must be completed by any and all witness to a job related injury.
  • WORK STATUS REPORT (PDF - 86kb)*: Employee should bring this form to each medical appointment. The medical provider must complete at every appointment, and employee must provide a copy to the supervisor/WCL.

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

** Microsoft Word (DOC) file requires the free Microsoft Word Viewer.

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