A school district, being a dynamic environment, sometimes experiences accidents to employees. Should you experience a work related injury, please contact your supervisor immediately to fill out the appropriate forms. 

Employee's instructions in the event of a workplace injury: 

• Employee should immediately contact Company Nurse Hotline at 1-877-816-0611, or if the employee needs immediate medical treatment, call 911 

• Employee receives and completes the following information and forms:

**Receipt of Workers’ Compensation Information form 

**Workers’ Compensation Injury Questionnaire form  

**DWC-1 Claim Form (Employee section numbers 1 thru 9 only) (effective 9/1/2021)

   Mitchell ScriptAdvisor First Fill - Temporary Prescription Card (effective 9/1/2021)

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English 

   Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish

• • WellComp Access to Medical Care Information: English and Spanish

**Employee must have contacted the Company Nurse Hotline and completed these 3-forms to initiate a claim. Please return all completed forms to your immediate supervisor, and/or send to Carol Gerken in the MBUSD Business Services office (EMAIL: [email protected]  or FAX: 310-303-3823)

Supervisor's instructions in the event of a workplace injury:  

• Supervisor must provide employee with the required forms and informational pamphlets noted above as soon as they are aware of the injury.   

• Please ensure employee contacts Company Nurse Hotline at 1-877-816-0611. 

• Supervisor must complete and return the Supervisor Report of Injury form to the MBUSD Business Service office along with the employee's required forms noted above.  

MANDATORY WORKPLACE WORKERS' COMPENSATION POSTERS/FLYERS:  Please post the following on all staff information bulletin boards or the like:

Notice to Employees--Injuries caused by Work (CA DIR)

Workers' Compensation Fraud

Company Nurse Hotline Flyer

Concentra Urgent Care (First Care Provider)

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - English

Medical Provider Network (MPN) Informational Pamphlet (WellComp) - Spanish

• • YOUR DOCTOR MUST SIGN THIS FORM, agreeing to treat you as a workers' compensation patient prior to you getting injured.  If you are injured at work without a pre-designated doctor on file, you will be treated by doctors at Concentra.