Formerly Known As Policy Number: 25.6
This Guide Memo lists forms needed to fulfill federal and state requirements concerning accidents, incidents, or exposures to employees in the workplace. It does not cover mental stress claims; contact your local Human Resources office immediately for guidelines on such claims. These policies also apply at SLAC National Accelerator Laboratory (SLAC). SLAC employees must report accidents, incidents or exposures to SLAC Medical Department.
1. Benefits Brochure
Detailed information about Stanford University Workers' Compensation benefits is available at the Stanford Risk Management website.
2. Where to Obtain Forms
- Cal-OSHA Form 5020 (Employer's Report of Industrial Injury)
- DWC Form-1 (Employee's Claim for Workers' Compensation Benefits)
- SU-17 (Accident/Incident/Exposure Report)
- Employee Personal Physician Pre-Designation Form
3. Report Required for Every Injury
In the event of an employee accident, incident or exposure, the injured or exposed person's supervisor must complete and submit an Accident/Incident/Exposure Report (Form SU-17). In addition, the supervisor must comply with state and federal reporting requirements, including prompt submission of Form SU-17. This form enables Environmental Health and Safety to implement thorough accident investigations to remedy work-related hazards.
Nonemployee accidents require an SU 17-B.
a. Time Limit
The SU-17 must be submitted within 24 hours of the occurrence.
The SU-17 applies to all employees (full-time, part-time and temporary), as well as to all students, contractors and visitors on campus, whether or not the injured or exposed person received medical attention.
c. Who Signs
The SU-17 must be completed accurately and signed by both the injured or exposed party and their supervisor. If the injured or exposed party is not a Stanford employee, the supervisor or manager responsible for the area where the injury, incident, or exposure occurred should sign the SU-17. If it is difficult to obtain the injured or exposed party's signed portion, departments should submit the supervisor's statement immediately, and the injured or exposed party's statement as soon as it is available.
d. Where to Submit
Mail or deliver the original and two copies along with Cal-OSHA Form 5020, if needed (see section 5) to Risk Management, 505 Broadway, 6th Floor, Redwood City, CA 94063, Mail Code 6207. Retain one copy for department files.
4. Report Required When a Doctor is Seen
An Employee's Claim for Workers' Compensation Benefits (DWC Form 1) must be given immediately to the employee along with the current year Workers' Compensation benefits sheet when a doctor is seen concerning the injury, incident or exposure. Failure to comply with the state requirements may impose significant fines and penalties, charged to the appropriate department. The DWC Form-1 and a detailed instruction sheet are available from Risk Management, 505 Broadway, 6th Floor, Redwood City, CA 94063, Mail Code 6207, phone 650/723-7400.
a. Time Limit
The DWC Form-1 must be signed by a University representative, and then given or mailed to the employee within 24 hours of the accident, incident or exposure.
The DWC Form-1 applies to all employees (full-time, part-time and temporary) when the injured or exposed person receives medical attention.
c. Who Signs?
The employer/supervisor/administrator signs the employer section. The injured person is not required to sign.
d. Where to Submit
A copy of the form must be sent to Risk Management for verification of employer obligation.
5. Additional Report When Medical Assistance Is Needed or One or More Days Are Lost From Work
State law requires that an Employer's Report of Industrial Injury (Cal-OSHA Form 5020) be submitted when an industrial injury or occupational disease results in:
- lost time beyond the day of injury, or
- medical treatment by a physician in a clinic, hospital, emergency room, or medical office.
Cal-OSHA Form 5020 is required for payment for medical services and is the basis for any disability claim under Workers' Compensation Insurance. See Guide Memo 2.1.7: Sick Time, concerning absences due to work-related disabilities and medical coverage under Workers' Compensation Insurance.
a. Typed Entry Required
The Cal-OSHA Form 5020 must be typed.
b. Time Limit
The Cal-OSHA Form 5020 must be submitted within 24 hours of the occurrence.
The Cal-OSHA Form 5020 applies to Stanford employees only. This includes part-time and temporary Stanford employees, but does not include independent contractors; persons employed by temporary help/employment agencies or vendors; or employees of other employers on campus, such as Stanford Bookstore.
d. Who Signs?
The injured employee's supervisor or acting supervisor signs the Cal-OSHA Form 5020.
e. Where to Submit
Mail or deliver the original and two copies of Cal-OSHA Form 5020, accompanied by the original and two copies of the SU-17, and the DWC Form-1 signed by a University representative, to Risk Management, 505 Broadway, 6th Floor, Redwood City, CA 94063, Mail Code 6207.