I of the Report of Employee Injury Form. Complete Part II of the Report of Employee Injury Form.
Department retains pink copy of the form.
Sign for the Employer Representative on Line 16. Forward the two top copies of the Employee's Claim for Workers' Compensation Benefits form and the Report of Injury form to Personnel Services. Give the employee the Workers' Compensation Benefits brochure and summary sheets. If the employee requires more than first aid treatment, the supervisor should complete the Medical Service order and send the to St. Jude's Industrial Medical Clinic, located in the Emergency Room. St. Jude's is located at the corner of Bastanchury and Harbor in Fullerton.