California

WORK RELATED INJURY PROCEDURE

PDF Refused Medical Treatment Forms

• Form 1 – Employee’s Report of Injury
• Form 5 – Supervisor’s Report
• Form D – Refusal of Medical Treatment

PDF Sent to Medical Forms

• Form A – 5020
• Form B – DWC Botton-Portion
• Form C – Auth. for Treatment
• Form 1 – Employee’s Report of Injury
• Form 3 – Consent to Release Medical Information

• Form 4 – WC Supplemental Forms
• Form 5 – Supervisor’s Report of Injury
• Form 6 – Accident-Root Cause
• Form 7 – Witness Statements
• Form 8 – Modified Duty Form

CA Claims Kit

• CA Claims Kit