Before an Incident Occurs
Designation of Personal Physician
This form is to be completed if you wish to designate your physician to treat you in the event of a work related injury or illness. You must submit this form to UEI Human Resources before a work related injury or illness occurs.
After an Incident Occurs
Workers’ Compensation Guide for Managers and Supervisors
The purpose of this guide is to help supervisors and managers understand the workers’ compensation process at University Enterprises, Inc. when an employee becomes ill or injured.
Workers’ Compensation Guide for Employees
The purpose of this guide is to help employees understand the workers’ compensation process at University Enterprises, Inc. and to become familiar with the procedures required when a work-related injury or illness occurs.
What To Do When You Have a Work-Related Injury or Illness On the Job Flier
Flier on what to do when a UEI employee working on the Sacramento State campus has a work-related injury or illness on the job.
Reporting a Work Related Injury/Illness
Instructions for reporting a work related injury/illness for both emergency and non-emergency situations.
Accident Report – Work Related Injury/Illness
This form represents both the original notification of work-related injury/illness and detailed report of the injury/illness. This form is to be completed by the supervisor and employee within 24 hours of injury/illness.
Workers’ Compensation Claim Form (DWC1)
This form is to be completed by the employee and UEI Human Resources or employer representative (i.e. supervisor) for work related injury/illness that results in lost time beyond the date of injury/illness or which results in medical treatment beyond first aid.
Returning to Work
Requirements for the supervisor when an employee is returning to work following a work related injury/illness.
Medical Provider Network
Group of health care providers in the Sacramento area set up to treat UEI employees injured on the job.
Statewide Kaiser Occupational Health Center Locations and Contact Phone Number
A list of Kaiser occupational health center locations and contact phone number for UEI employees who do not live or work in the Sacramento area. These centers are set up to treat UEI employees injured or became ill on the job.
Kaiser On-The-Job Occupational Health Treatment Referral Form
This form authorizes Kaiser Health Center to provide a UEI employee treatment for a work related injury/Illness. Contact UEI Human for authorization signature. Please call ahead for on the job injury/illness care to ensure timely treatment.
Release of Information Forms
Concentra Authorization for Examination or Treatment Form
This form authorizes Concentra Clinic (formerly U.S. HealthWorks) to provide a UEI Employee treatment for a work related injury/Illness. Contact UEI Human Resources for authorization signature. Please call ahead for on the job injury/illness care to ensure timely treatment.
Authorization for Exchange and Disclosure of Protected Health Information
If treated for a work related injury/Illness at the Student Health and Counseling Services (SHCS), this form authorizes the SHCS to disclose/exchange information contained in your medical record between SHCS and UEI Human Resources for your work status (i.e. Off full duty or restricted duty). Contact UEI Human Resources for authorization signature.