Workers' Compensation Forms
Employer's Report
University policy requires that industrial injury/illness be reported to Workers' Compensation within one working day of occurrence. This form must be completed in its entirety and sent to Workers’ Compensation within 24 hours of notification of injury.
Facts Pamphlet
This state mandated form must be given to new employees within the first two weeks of employment. It is part of the informational packet at New Employee Orientation. The information in this pamphlet is available in Spanish. To obtain a copy, please call Workers’ Compensation at (530) 757-3266.
Modified Duty Program
This brochure answers common questions regarding the UC Davis Modified Duty Program.
Physician Designation
An employee uses this form to designate his or her personal physician to provide treatment in the event of a work-incurred injury or illness. See P&P 370-20 for further information.
Poster
California law requires that departments conspicuously display this poster where it can be read by the employees.
Volunteer Information Record
This form is used to obtain demographic information from volunteers and volunteer activity information from departments. The form should be completed by all non-employee volunteers. The purpose of the information is to determine eligibility for possible workers compensation benefits in the event that the individual is injured while providing volunteer services to the University.