Stanford University
Workers' Compensation Benefits

Initial Injury/Exposure Reporting Check List

Frequently Asked Questions (Including Stress Claims)

What is Workers’ Compensation?

One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

-or-

Repeated exposures at work. Examples: hurting your wrist from using vibrating tools, losing your hearing because of constant loud noise.

-or-

Workplace crime. Examples. you get hurt in a store robbery, physically attacked by an unhappy customer.

What are the benefits?

Medical Care: Paid for by your employer to help you recover from an injury or illness caused by work. Doctor visits, hospital services, physical therapy, lab tests and X-rays are some of the medical services that may be provided. These services should be necessary to treat your injury. There are limits on some services such as physical and occupational therapy and chiropractic care.

Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering. The amount you may get is up to two-thirds of your wages. There are minimum and maximum payment limits set by state law. You will be paid every two weeks if you are eligible. For most injuries, payments may not exceed 104 weeks within five years from your date of injury. Temporary disability (TD) stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it’s going to.

Permanent disability benefits: Payments if you don’t recover completely. You will be paid every two weeks if you are eligible. There are minimum and maximum weekly payment rates established by state law. The amount of payment is based on:

• Your doctor’s medical reports
• Your age
• Your occupation

Supplemental job displacement benefit: This is a voucher for up to $6,000 that you can use for retraining or skill enhancement at an approved school, books, tools, licenses or certification fees, or other resources to help you find a new job. You are eligible for this voucher if:

• You have a permanent disability
• Your employer does not offer regular, modified, or alternative work, within 60 days after the claims administrator receives a doctor’s report saying you have made a maximum medical recovery

Death benefits: Payments to your spouse, children or other dependents if you die from a job injury or illness. The amount of payment is based on the number of dependents. The benefit is paid every two weeks at a rate of at least $224 per week. In addition, workers’ compensation provides a burial allowance.

Other benefits

You may file a claim with the Employment Development Department (EDD) to get state disability benefits when workers’ compensation benefits are delayed, denied, or have ended. There are time restrictions so for more information contact the local office of EDD or go to their web site www.edd.ca.gov.

If your injury results in a Permanent Disability (PD) and the state determines that your PD benefit is disproportionately low compared to your earning loss, you may qualify for additional money from the Department of Industrial Relation’s special earnings loss supplement program also known as the return to work program. If you have questions or think you qualify, contact the Information & Assistance Unit by going to www.dwc.ca.gov and looking under "Workers’ Compensation programs and units" for the "Information & Assistance Unit" link or visit the DIR web site at www.dir.ca.gov.

The State Law excludes disability payments for the first three days off (including weekends) unless you are off work 14 days or more or become hospitalized. Stanford's policy is to waive the waiting period and pay full salary for the remainder of the day in which the injury occurred and the three-day State required waiting period, plus two additional days. This five-day period is not charged to sick leave or vacation. After the five-day period, accumulated sick leave and/or vacation may be used to supplement Workers' Compensation benefits, thus continuing income equivalent to full pay. Stanford Disability and Leave Services (DLS) processes and coordinates all disability leaves of absence (LOA) with Payroll, including those for workers’ compensation, as part of the Stanford salary continuation program. Thus, the employee’s DLS representative needs to be informed about all Workers’ Compensation LOAs in order to calculate, coordinate and administrate accurately and in a timely manner all pay for which the employee is eligible. DLS can be reached at hrleaves@stanford.edu. Employees may request clarification from Administrative Guide memos 2.1.6, 2.1.7, 7.2.1, 7.6.1 and 2.3.5.

If you have any questions concerning your claim for benefits, please feel free to contact Risk Management at (650) 723-7400. SLAC employees may contact the Safety Department at extension 4533.

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Workers’ compensation fraud is a crime Any person who makes or causes to be made any knowingly false statement in order to obtain or deny workers’ compensation benefits or payments is guilty of a felony. If convicted, the person will have to pay fines up to $150,000 and/or serve up to five years in jail.

What should I do if I have an injury?

Report your injury to your employer.

Tell your supervisor right away no matter how slight the injury may be. Don’t delay - there are time limits. You could lose your right to benefits if your employer does not learn of your injury within 30 days. If your injury or illness is one that develops over time, report it as soon as you learn it was caused by your job. SLAC employees MUST report the accident/exposure to the SLAC Medical Department, extension 2281, you will then be asked to complete a claim form.

If you cannot report to the employer or don’t hear from the claims administrator after you have reported your injury, contact the claims administrator yourself.

You may be able to find the name of your employer’s workers’ compensation insurer at www.caworkcompcoverage.com. If no coverage exists or coverage has expired, contact the Division of Labor Standards Enforcement at www.dir.ca.gov/DLSE as all employees must be covered by law.

Get emergency treatment if needed. If it’s a medical emergency, go to an emergency room right away. Tell the medical provider who treats you that your injury is job related. Your employer may tell you where to go for follow up treatment. If you experience ambulance transportation due to your work related incident, submit any bills you receive to your claim administrator. Ask your HR representative for the necessary contact information.

Unless you have previously predesignated your personal physician (in writing) all medical care for the first 30 days of treatment should be obtained from Stanford University Occupational Health Center (SUOHC), 480 Oak Road, Phone: (650) 725-5308 Fax: (650) 725-9218, hours from 8:00 AM to 5:00 PM. For urgent medical care after SUOCH hours go to the Acute Care Center within the Emergency Room at Stanford Hospital and Clinics the phone is (650) 723-5111. For life threatening emergencies go to the nearest Emergency Room or the Acute Care Center within the Emergency Room at Stanford Hospital and Clinics the phone is (650) 723-5111.

Emergency telephone number: Call 911 (outside), 9-911 (inside) or 286 for SOM for an ambulance, fire department or police. For non-emergency medical care, contact your employer, the workers’ compensation claims administrator or go to this facility: SUOHC, 480 Oak Road, Phone: (650) 725-5308

Fill out DWC 1 claim form and give it to your employer. Your employer must give you a DWC 1 claim form within one working day after learning about your injury or illness. Complete the employee portion, sign and give it back to your employer. Your employer will then file your claim with the claims administrator. Your employer must authorize treatment within one working day of receiving the DWC 1 claim form.

If the injury is from repeated exposures, you have one year from when you realized your injury was job related to file a claim.

In either case, you may receive up to $10,000 in employer-paid medical care until your claim is either accepted or denied. The claims administrator has up to 90 days to decide whether to accept or deny your claim. Otherwise your case is presumed payable.

Your employer or the claims administrator will send you "benefit notices" that will advise you of the status of your claim.

More About Medial Care

What is a Primary Treating Physician (PTP)?

This is the doctor with overall responsibility for treating your injury or illness. He or she may be:

• The doctor you name in writing before you get hurt on the job
• A doctor from the medical provider network (MPN)
• The doctor chosen by your employer during the first 30 days of injury if your employer does not have an MPN
• The doctor you chose after the first 30 days if your employer does not have an MPN

What is a Medical Provider Network (MPN)?

An MPN is a select group of health care providers who treat injured workers. Check with your employer to see if they are using an MPN.

If you have not named a doctor before you get hurt and your employer is using an MPN, you will see an MPN doctor. After your first visit, you are free to choose another doctor from the MPN list.

What is predesignation?

Predesignation is when you name your regular doctor to treat you if you get hurt on the job. The doctor must be a Medical Doctor (M.D.), Doctor of Osteopathic Medicine (D.O.) or a medical group with an M.D. or D.O. You must name your doctor in writing before you get hurt or become ill.

You may predesignate a doctor if you have health care coverage for non-work injuries and illnesses. The doctor must have:

• Treated you
• Maintained your medical history and records before your injury
• Agreed to treat you for a work-related injury or illness before you get hurt or become ill

You may use the "predesignation of personal physician" form in this web-site. After you fill in the form, be sure to give it to your employer.

For your convenience, here is a link containing an optional form that you can use to predesignate your personal physician and give to your employer. Predesignation of Personal Physician Form

If your employer does not have an approved MPN, you may name your chiropractor or acupuncturist to treat you for work related injuries. The notice of personal chiropractor or acupuncturist must be in writing before you get hurt. You may use the form in this web-site. After you fill in the form, be sure to give it to your employer.

For your convenience, here is a link containing an optional form that you can use for your chiropractor or acupuncturist and give to your employer. Notice of Personal Chiropractor or Personal Acupuncturis

With some exceptions, state law does not allow a chiropractor to continue as your treating physician after 24 visits. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. The term "chiropractic visit" means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management.

Exceptions to the prohibition on a chiropractor continuing as your treating physician after 24 visits include postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule, or if your employer has authorized additional visits in writing.

What if there is a problem?

If you have a concern, speak up. Talk to your employer or the claims administrator handling your claim and try to solve the problem. If this doesn’t work, get help by trying the following:

Contact the Division of Workers’ Compensation (DWC) Information and Assistance (I&A) Unit

All 24 DWC offices throughout the state provide information and assistance on rights, benefits and obligations under California’s workers’ compensation laws. I&A officers help resolve disputes without formal proceedings. Their goal is to get you full and timely benefits. Their services are free.

To contact the nearest I&A Unit, go to www.dwc.ca.gov and under “Workers’ Compensation programs and units”, click on “Information & Assistance Unit.” At this site you will find fact sheets, guides and information to help you.

Consult with an attorney

Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fees may be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www.californiaspecialist.org. You may get a list of attorneys from your local I&A Unit or look in the yellow pages.

Warning Your employer may not pay workers’ compensation benefits if you get hurt in a voluntary off-duty recreational, social or athletic activity that is not part of your work-related duties.

Note to Employees and Supervisors

• Initial Injury/Exposure Reporting Check List is a link listing what is needed to initially report an injury/exposure.
• Disability and Leaves Services (DLS) must be contacted in order to facilitate payment of Disability benefits when employee will be losing time beyond the date of injury.
• SU-17 completed for any accident, incident or exposure involving a Stanford University employee. Must be processed within 24 hours. This form is available through this web site. Fax to Risk Management at (650) 723-9456. Submit original to Risk Management, Mail Code 6207.
• SU-17B  completed for any accident, incident or exposure involving a visitor, contractor, etc. Must be processed within 24 hours. This form is available through this web site. Fax to Risk Management at (650) 723-9456. Submit original to Risk Management, Mail Code 6207.
• State Form DWC-1 provided to Employee for notification of their right to file a Workers’ Compensation claim. Before providing to employee, partially complete as directed on instruction cover sheet and make one copy. Form must be provided to employee within 24 hours. Employee completes and signs top section if they want to file a claim for a work related injury or illness when one or more workdays is lost or when treatment is provided in a medical facility. This form is available through this web site. It is also available from Risk Management at phone: (650) 723-7400. Fax copy of the DWC-1 given the employee to (650) 723-9456. Once signed by employee, submit original and one copy to Risk Management, Mail Code 6207.
• CAL OSHA 5020 completed for employees when one or more workdays are lost or when treatment is provided in a medical facility. This form must be typed and is available through this web-site. Submit original to Risk Management, Mail Code 6207.
• SU-16 completed when the employee has lost one or more full days of work or had restricted work activity due to a work-related injury or illness. Submit to Risk Management on-line once employee has been released to full work duties.