FORMS FOR DISTRICT USE

Workers' Compensation:

Employees are to report on the job injuries/illnesses immediately to supervisor and call Company Nurse Hotline (888)375-0280.

IA Reporting Procedure

Supervisor procedures regarding Industrial Accidents

Quick Guide

Quick reference guide for Industrial Accident Procedural Forms

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility

Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

Illness/Injured Employee Acknowledgement Form

Please return signed form to Administrative Services

Access to Medical Care (EIA MPN)

Your employer has elected to provide you with the choice of a broad scope of medical services for work-related injuries and illnesses by implementing a Medical Provider Network (MPN), called EIA MPN.

MEMORANDUM - Employee Notification (MEMORÁNDUM - Notificación al Empleado)

Workers' Compensation Medical Provider Network: EIA MPN (Red de Proveedores Médicos del Seguro de Indemnización por Accidentes de Trabajo: EIA)

Facts About Workers' Compensation

For dates of injury on or after January 1, 2013

Miscellaneous:

Incident/Damage/Vandalism Form

To be completed & submitted to the Administrative Services within 24 hours (cc a copy to M&O if repairs are needed).

Vehicle Accident Report

School Use Only:

Student Accident Report

This form should be completed for all injuries to students or non-students (other than district employees) and sent immediately to the assistant superintendent's office.

Insurance:

Student Insurance

Brochure and Application

Student Insurance - Spanish (Seguro Para Estudiantes)

Folleto y Aplicacíon

Parent Letter (Carta a los Padres)

Student Injuries and Insurance – 2012/13 School Year (Seguro de Accidente para Estudiantes – Año Escolar 2012-13)

Field Trips:

Parent Consent Form

Parent consent for field trip. Waiver of liability, assumption of risk, and indemnity agreement.

Parent Consent Form - Spanish (Consentimiento de Padres Para Viajar)

Dispensa de responsabilidad, aceptación de riesgos y acuerdo de indemnización.

Certificate of Liability Insurance Request Form:

SCSRM

Request for liability certificate of coverage.