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You can now fill out the Supervisor's Report (Form WCSR) online* as well as on a printed form! Take a look at the easy steps and the deadlines below, and then, if you'd like to fill out the form online, simply click on Supervisor's Report (Form WCSR)
*To access the form you will need Adobe Reader on your computer, available for free downloading from the Adobe
Web site or the full version of Adobe Acrobat Standard or Professional.
WITHIN FIVE DAYS of any knowledge of a work-related injury or
illness:
1. Have the employee's supervisor fill out the "Supervisor's Report of Work Injury" (Form WCSR), and
then either mail it, along with the completed "Employer's Report of Occupational Injury or Illness" (Form 5020), to California Fair Services Authority (CFSA), or submit both forms to CFSA electronically. Please provide as many details about the incident as possible.
You can either print out a copy of the Supervisor's Report to complete, or complete it online.
2. If you used the printed form, attach it 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
If you're using the online form: Click "PRINT AND SUBMIT" at the bottom of the form to simultaneously
submit it to CFSA and to open the print action window on your computer. In the print window, request two copies ~ an original that you'll sign and mail to CFSA (P.O. Box 15518, Sacramento, CA 95852), and a second copy for your files. Make sure you also send CFSA an electronic or print copy of your "Employer's
Report of Occupational Injury or Illness" (Form 5020).
Want to save a copy of your completed Supervisor's Report?
You can if you have a full version of the Adobe Acrobat software program (not just Adobe Reader)
on your computer. To ensure that
the form opens with your Acrobat program (so that you are able to save it), you’ll need to check your Acrobat “Preferences” settings. Here's how:
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Open Adobe Acrobat.
Click on “Edit” in the main menu bar and then click on “Preferences” in the “Edit” menu.
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In the “Preferences” window, click on “Internet” in the left hand “Categories” column. If the boxes for “Display PDF in browser”, “Allow fast Web view”, and “Allow speculative downloading in the background” aren’t checked, do so by clicking each box with
your mouse.
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Click “OK” to close the “Preferences” window.
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Close Acrobat. The next time you open the Supervisor's Report PDF from CFSA’s Web site, it will automatically
open in Adobe Acrobat and you can save the form just as you would save any other
PDF document.
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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 our 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. 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.
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Supervisor's