Refer the employee injured on the job to the Occupational Health (OH) during regular working hours. After hours, weekends, and holidays refer to Ronald Reagan UCLA Medical Center Emergency Department for EVALUATION AND TREATMENT.
Employees should be provided with:
- A completed EMPLOYEE'S CLAIM FORM FOR WORKERS' COMPENSATION BENEFITS. This form must be provided within 24 hours of receipt of notice that an injury or illness has occurred as mandated by California State law. (exception: First Aid incidents)
- A completed EMPLOYEE'S REFERRAL SLIP FOR INDUSTRIAL INJURY AND REPORT OF ACCIDENT
- UCLA Healthcare Workers' Compensation Pamphlet When An Injury Occurs & Workers' Comp Information Sheet
Incident Reporting and Referral for Medical Treatment Forms (Fillable pdf)
Concentra Employer Authorization Form
- 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.
Student Worker Employment Verification (Fillable pdf)
NOTIFY UCLA Health Human Resources Workers' Compensation at (310) 794-0500 or Risk Management at [email protected] as soon as you are aware that an employee has been taken off work.
NOTIFY your Department Personnel/Payroll representative to begin appropriate payroll process.
Call Occupational Health at (310) 825-6771 to schedule follow up appointments for workers compensation injuries.