A safe working environment is a high priority for the Temecula Valley Unified School District. However, should you become injured or ill, as a result of your job, we want to ensure you receive prompt, quality medical treatment. Using the links provided in the section below will provide you and the appropriate site personnel with the information and documents each of you will need if you are injured at work.
Documents and Forms
Employee's Statement - Decline Medical - form to be completed by injured employee (no medical treatment necessary) and signed by a site representative. No other forms need to be completed if the injured employee does not wish to seek medical treatment.
For injured employees wishing to seek medical treatment, please complete all the forms listed below. Copies of the Instructions for the Injured Worker, Employee Rights, and Notification of Potential Eligibility, along with a copy of the completed forms, should be provided to the injured emoployee.
- Employee's Statement - form must be completed by injured employee (medical treatment necessary)
- Supervisor's Report - form must be completed by supervisor of injured employee & employee together
- Medical Claims History - form must be completed by employee.
- Medical Records Release - form must be completed by employee.
- Witness' Report - form must be completed by all witnesses to injury
- Authorization for Medical Treatment - form must be completed by injured employee and signed by supervisor
- DWC-1 Claim Form - form must be completed by injured employee and site representative
- Notification of Potential Eligibility (NOPE) - Must be printed and given to injured employee
- Medical Provider Network - Must be printed and given to injured employee (Spanish)
- Employee Rights - Must be printed and given to injured employee (Spanish)
- Instructions for the Injured Worker - Must be printed and given to injured employee
- WHOLE Packet (Includes ALL of the above forms) - WHOLE packet must be printed and completed as noted above
If you wish to have your primary care doctor treat you in case of a work-related injury, please print the form below and follow the instructions. Your primary treating physician must put in writing his/her willingness to treat you under the workers' compensation regulations. The doctor may use the form below.
The completed form or letter must be on file prior to your injury for the pre-designation to be in effect.
Pre-Designation Form - English
Pre-Designation Form - Spanish