Systemwide Risk Management

Workers' Compensation Forms

The forms referenced on this page are the state required Workers' Compensation forms. Employees should contact their supervisor or campus Workers' Compensation Coordinator to obtain campus-specific forms.

Workers' Compensation New Hire Pamphlet
CSU provides a pamphlet to NEW employees regarding worker's compensation, also referred to as the "Time of Hire Pamphlet". The content for this pamphlet is specified in Labor Code 3551 and Section 9880 of Title 8, California Code of Regulations. The Administrative Director must approve all pamphlets per Regulation 9883. The approved pamphlets are available through the California Workers' Compensation Institute (CWCI) and may be ordered on-line at www.cwci.org or by calling 510-251-9470.

The Time of Hire Pamphlet shall be given to new employees by the time of their first paycheck.

Workers' Compensation Claim Form
The current version of the Workers' Compensation Claim Form, known as the DWC1 (.pdf) form, is dated 7/1/2004. Each campus uses a multi-part form that is pre-printed with the address of the claim office. A supply of pre-printed forms for your campus may be obtained by contacting the Chancellor's Office (see below).

The DWC1 Claim Form is given to injured workers within one day of the knowledge of an injury.

Workers' Compensation Predesignated Personal Physician Forms
The current versions of the forms are the Predesignated Personal Physician (.pdf) and the Notice of Personal Chiropractor or Personal Acupuncturist (.pdf). These forms are dated 3/14/2006 and can be found on the Division of Workers' Compensation (DWC) website.

These forms are given to new employees. Current employees may also use these forms to change their election.

RESOURCES

Jacki Graf
Workers' Compensation Consultant
(415) 403-1438

Request DWC1 Forms:
Leona Ching
(562) 951-4580

Useful Forms Websites:


Content Contact:
Rebecca Skidmore
(562) 951-4580
Technical Contact:
webmaster@calstate.edu
Last update: July 25, 2006