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Worker's Compensation

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. 
 

What To Do When An Employee Is Injured At Work

documents and forms

Employee's Statement - Decline Medical -  form to be completed by injured employee (no medical treatment necessary).  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 to be completed by injured employee (medical treatment necessary)

Supervisor's Report  - form to be completed by supervisor of injured employee

Medical Claims History   - form to be completed by employee.

Medical Records Release - form to be completed by employee.

Witness' Report - form to be completed by all witnesses to injury

Authorization for Medical Treatment   - to be completed by injured employee and signed by supervisor

DWC-1 Claim Form - to be completed by injured employee and site representative

Notification of Potential Eligibility (NOPE) - copy to injured employee

Medical Provider Network - copy to injured employee (Spanish)

Employee Rights - copy to injured employee (Spanish)

Instructions for the Injured Worker   - every injured employee should receive a copy of this document

physician pre-designation

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 sign the form indicating whether s/he is willing to treat you under the workers' compensation regulations.

The completed form must be on file prior to your injury for the pre-designation to be in effect.

Pre-Designation Form

new hire documents

General Responsibilities - all new employees are required to print, complete/sign, and return to Risk Management.

New Employees are responsible for reading the notifications listed below:

MPN Information/Access (English)

MPN Information/Access (Spanish)

NEW MEDICAL PROVIDER NETWORK - 7/1/2012

Below are documents associated with the District's new Medical Provider Network (MPN) effective July 1, 2012.  Please click on the title to view/download/print.

MPN Implementation Notice

MPN Information/Access (English)

MPN Information/Access (Spanish)

MPN DWC7 Poster (English/Spanish)