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When a work-related accident or illness occurs, the injured
employee's supervisor must:
1. Fill out a "Supervisor's
Report of Work Injury" (Form WCSR) providing as much detail
as possible about the incident.
2. Attach the completed form to the "Employer's
Report of Occupational Injury or Illness" (Form 5020) and send
both forms to:
California Fair Services Authority
Attn: Workers' Compensation Claims Administrator
P.O. Box 15518
Sacramento, CA 95852-0518
3. Bring the accident up at the next safety meeting and identify
the steps needed to prevent a recurrence.
4. Re-evaluate the existing Form WPP-01, "Job Safety Analysis"
(JSA), for the task being performed at the time of the accident
and make any revisions to prevent a recurrence. If there's no existing
form, put one into place.
When a serious accident
or fatality occurs:
1. Notify CFSA's Workers' Compensation Department at 916/263-6172, and Safety
Department at 916/263-6186, immediately (or call CFSA's mainline at 916/921-2213. We can help with accident investigation
at the scene or by phone.
2. Notify Cal-OSHA within eight hours of the incident. (A
list of Cal-OSHA offices throughout California is in your fair's
Red Book (Claims and Loss Reporting Guide) under Workers'
Compensation, Tab 5. It's helpful to complete the Cal-OSHA "Accident
Notification" form before calling so you can refer to it. A "serious
accident" in this instance means any injury or illness occurring
in a place of employment or in connection with any employment requiring
inpatient hospitalization in excess of 24 hours for other than medical
observation, or in which an employee suffers a loss of any member
of the body or suffers any serious degree of permanent disfigurement.
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Supervisor's