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. 

NEW! The Workers' Compensation information and claim forms are now available via Informed K12. Click here to access the forms: Workers' Comp Claim Form on Informed K12.

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

• Employee: Immediately contact Company Nurse Hotline at 1-877-816-0611, or if the employee needs emergency medical treatment, call 911 

• Employee receives and completes the following Workers' Compensation information and reporting forms (these forms can also be received and completed online via Informed K12 (click here):

**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:

The Company Nurse Hotline

Concentra Locations

Notice to Employees--Injuries caused by Work (CA DIR DWC-7)

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.