7.6.1 Employee Work-Related Incident Reporting

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Approved by the Senior Associate Vice President and Chief Risk Officer, Office of the Chief Risk Officer, Business Affairs.
Last Updated

Formerly Known As Policy Number: 25.6

This Guide Memo lists forms needed to fulfill Stanford’s employee work-related incident reporting protocol as well as documents required under Federal and State law concerning potential Workers’ Compensation benefits. Stanford’s Workers' Compensation Program is managed by the Office of Risk Management and Insurance (RMI).

Other actions beyond reporting, including seeking medical treatment may be necessary. Please refer to RMI’s website (https://orm.stanford.edu/), or reach out to your local HR Representative for more information.

These policies also apply at SLAC National Accelerator Laboratory (hereafter “SLAC”).

This Guide Memo does not cover mental health concerns. Contact your local HR office or RMI for guidance on such matters.

For emergencies, STOP and call 911.

1. Reporting Required for Every Employee Work-Related Incident

Stanford is committed to keeping a safe environment for its employees. Incidents involving injury, illness, or exposure must be reported within 24 hours of occurrence. This reporting helps identify opportunities to improve Stanford’s future safety and avoid problems/delays in receiving benefits (if applicable), including medical care.

a. When an Employee Work-Related Incident occurs at work, employees must immediately take the following steps:

Step 1:  Seek medical treatment as needed.
Step 2:  Report the Incident(s) to your Manager/Principal Investigator (PI) immediately. 
Step 3:  Complete necessary documentation.

Managers must inform their local Human Resources (HR) Representative, as more requirements may apply.

b. What is an incident?

An incident is defined as:

  • an occurrence that results in unintended injury or illness,
  • an exposure to a hazardous substance, 
  • an exacerbation of a pre-existing condition, or
  • a close-call event that could have resulted in bodily injury but did not.

Any work-related incident that requires immediate medical attention (for example, incidents resulting in an employee’s death, amputation, loss of an eye, any serious degree of permanent disfigurement, possible in-patient hospitalization, or any life-threatening incident) must be reported immediately to:

  • Stanford Environmental Health & Safety (EH&S) at: 650-725-9999 (for non-SLAC University employees), or
  • SLAC Environmental Safety & Health (ESH) at: 650-926-5555 (for SLAC employees), and
  •  Risk Management and Insurance by SECURE: email at workerscomp@stanford.edu (mailto:workerscomp@stanford.edu)

2. Forms

The following section describes work-related incident reporting documents. All forms can be found on the Risk Management and Insurance website (https://orm.stanford.edu/forms).

a. Required for All Incidents: 

(1) Incident Report (SU-17): This form is Stanford’s tool for capturing, recording, and addressing an employee work-related incident. This form enables safety professionals and managers across the University and SLAC to identify trends, analyze the root cause of an incident, and identify areas of opportunity to improve future safety. Managers/PIs must comply with state and federal reporting requirements, including prompt submission of the SU-17.      

EH&S, ESH, and/or RMI may contact the person(s) involved, their Manager/PI(s), and/or their local HR to gather additional information and initiate follow-up steps.

Once a report is submitted, the supervisor/manager will receive an email with a direct link to complete the Manager/PI Follow up section. The Manager/PI will receive an email with a copy of the SU-17 once the report is complete. This should be forwarded to the local HR representative. 

(2) Time Requirement: After an incident occurs, it must be reported using the Incident Report SU-17 form, either by the employee or on behalf of the employee within 24 -hours of occurrence.

(3) Applicability: The Incident Report SU-17 applies to all employees (as defined in Guide Memo 2.2.1: Definitions). It is applicable whether the person involved received medical attention or not. 

b. For the Employee to file a Workers’ Compensation Claim:

(1) Employee’s Workers’ Compensation Claim Form (DWC1 Form) and Notice of Potential Eligibility: This form is a California state document. The employer provides the DWC1 form to an employee who reports a workplace incident.

(2) Time Requirement: California law requires that within 24 hours of receiving notice or knowledge of injury, illness, or exposure, the employer must provide the DWC1 claim form to the injured worker or their dependents. Failure to comply with state requirements may result in significant fines and penalties, charged to the appropriate department.

(3) Applicability: The DWC1 Claim Form applies to employees of Stanford/SLAC who wish to file a workers’ compensation claim. 

If the injured worker wishes to file a workers’ compensation claim or seeks medical treatment, the DWC1 Claim form must be completed accurately and signed by the injured worker and a representative of Stanford/SLAC. 

This form is not intended for non-employees.

(4) Where to Submit: A copy of the form must be sent to RMI via SECURE: email at workerscomp@stanford.edu (mailto:workerscomp@stanford.edu)

c. For local HR/Manager to complete if the employee files a Workers’ Compensation Claim:

(1) Employer’s Report of Occupational Injury or Illness (5020 form): This form is a California state document. The employer is required to complete a 5020 form for all workers’ compensation claims.

(2) Time Requirement: California law requires employers to file this report with their workers’ compensation insurer within five days of knowledge. Failure to comply with the state requirements may result in significant fines and penalties, charged to the appropriate department.

(3) Applicability: The 5020 form must be completed by a representative of Stanford/SLAC (generally local HR) for employees who have filed a workers’ compensation claim. California law requires it to be completed by the employer, not by the employee. 

This form is not intended for non-employees.                                       

(4) Where to Submit: A copy of the form must be sent to RMI via SECURE: email at workerscomp@stanford.edu (mailto:workerscomp@stanford.edu)

d. For All Newly-Hired Employees

(1) Time of Hire Notice: This is a California state document that provides an overview of rights, benefits, and obligations under California workers' compensation law, including guidelines for employees to pre-designate a physician or medical group for work-related injuries and illnesses.

(2) Time Requirement: California law requires all employers to provide the Time of Hire Notice to each new employee, either at the time of hire or by the end of their first pay period. At Stanford, this document is provided to all New Hires as an attachment to Stanford’s employment offer letters. It can also be found on Stanford’s Welcome Center Onboarding Resources web page (https://cardinalatwork.stanford.edu/welcome-center/resources).

(3) The Time of Hire Notice and other documentation related to Workers’ Compensation at Stanford can also be found on the Risk Management and Insurance website (https://orm.stanford.edu/forms).

(4) Applicability: The employer must provide this notice to all newly hired employees in the State of California hired after January 1, 2013. Note: it is not required that employees complete this form; it is only required to be provided to newly hired employees.

(5) Where to Submit: If an employee completes any of the documents found in this Time of Hire Notice, the signed forms must be sent to RMI via SECURE: email at workerscomp@stanford.edu (mailto:workerscomp@stanford.edu).


Source URL: https://adminguide.stanford.edu/chapters/health-and-safety/accident-and-incident-reporting/employee-work-related-incident-reporting