Supervisor’s Report of Work Injury
How to Fill Out the Supervisor’s Report of Work Injury (Form WCSR)
This form is for use by California’s fairgrounds only.
WITHIN FIVE DAYS of any knowledge of a work-related injury or illness:
Step 1. Have the injured employee’s supervisor fill out the Supervisor’s Report of Work Injury (Form WCSR). You’ll find a blank report in your Red Book, under Workers’ Compensation, Section 3, or print out a copy from the link above. The form can also be filled out online (we recommend accessing the form using Chrome). Please provide as many details about the incident as possible.
Step 2. Fax or email a signed WCSR to CFSA along with a completed Employer’s Report of Occupational Illness or Injury (Form 5020). Remember to keep a second copy of both reports for your fair’s files.
Fax to: (916) 263-6159, attention Cindy Hehner
Email to: Cindy Hehner, CFSA’s Workers’ Compensation claims administrator, at firstname.lastname@example.org.
Step 3. Bring the accident up at the next safety meeting and identify the steps needed to prevent a recurrence.
Step 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 Cindy Hehner, CFSA’s Workers’ Compensation claims administrator, at (916) 263-6172, and Tom Amberson, CFSA’s Risk Department manager, at (916) 263-6180 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 (Subsection 4). 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 that requires 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.