double digital

Worker's Compensation, Employer's First Report of Injury or Illness Forms

Incident Reporting and Referral for Medical Treatment Forms (Fillable PDF)

Incident Reporting is required and ensures that there is a record on file with the employer. If an employee is injured or develops a job-related illness (developed gradually over time) as a result of their employment at UCLA, they must complete and submit these forms (see highlighted fields). If the employee is unable to complete these forms,the supervisor must complete it on their behalf. If an injury occurs, first aid may be the appropriate treatment.

Worker's Compensation, Prescriptions

How to Fill Prescriptions Form (Fillable PDF)

Optum has been chosen by UCLA to manage your worker's compensation pharmacy benefits. If you need prescriptions filled related to your injury, please follow the simple instructions on this form. In English and also en español.


Tuberculosis (TB) Screening Form

TB Screening Form (Fillable PDF)


Pre-Employment Forms 

Pre-Employment Forms Packet (Fillable PDF)


Tdap Declination Forms

Tdap Declination Form (Printable Form)


Hep B Declination Forms

 Hep B Declination Form (Printable Form)


Rabies Declination Forms

 Rabies Declination Form (Printable Form)