Workers' Compensation Clain Form DWC1
Employee's form for filing a Workers' Compensation claim and the Notice of Potential Eligibility for Workers' Compensation benefits.
This is a mandatory form to be given to any employee upon request, and within 1 day of the employer's knowledge of a work related injury/illness requiring medical treatment beyond first aid.
Multi-copies of the completed form are required to be distributed. DEPT must keep one copy. EMPLOYEE must receive one copy. Health System HR WC must receive one copy.
Incident Report and Referral for Medical Treatment
Multi-copy original form can also be ordered via EMPAC #313323
Notice to Employees - Injuries Caused By Work (2016)
Every employer shall post and keep posted in a conspicuous location frequented by employees during the hours of the workday this notice to employees. It must be posted in English and Spanish where there are Spanish speaking employees.