San José-Evergreen Community College District is committed to the safety and welfare of all employees through prevention, education, and awareness. Immediately notifying your supervisor of an unsafe condition is the responsibility of all employees.
Please refer to the Injury-Illness Prevention Plan (IIPP) for more information.
Keenan & Associates is the District’s Third Party Administrator for Workers’ Compensation. The Benefits Coordinator works closely with Keenan to assure that every injured/ill worker receives the proper medical care and benefits he/she is entitled to under workers’ compensation law. For questions about your claim or benefits, please call Keenan at 408.441.0876.
In the event of an Industrial or work-related injury or illness that does not require emergency medical attention, it is the injured/ill workers’ responsibility to immediately notify his/her supervisor or the Benefits Coordinator in Human Resources (408.223.6713 or extension 6713 from a district phone) for the proper forms to document the injury and receive direction on how to obtain medical attention, if necessary.
Employees may pre-designate their primary treating physician to treat them for any future work-related injury or illness by completing the form below with their primary treating physician. The physician’s signature is required. This form must be on file in Human Resources prior to the date of injury/illness.
Otherwise, all non-emergency treatment (including follow up appointments after an initial visit to an emergency room) must be received at an Concentra Occupational Medicine facility (formerly Alliance). Authorization for treatment will be provided by Human Resources.
It is the employee’s responsibility to assure the Pre-Designated Physician's form on file in Human Resources is up to date.
Workers’ Compensation Claim Forms & Information
Notice of Potential Eligibility & Workers’ Compensation Claim Form (DWC 1) – The employee must complete the top section of third page and return the original to Human Resources to file a claim.
Employer's Report of Occupational Injury or Illness (Form 5020) – The injured worker will be asked to complete this form, or assist his/her supervisor or Human Resources to complete it.
Employee Notification of Rights Materials (PRIME Plus MPN) – This pamphlet contains important information about your medical care in case of a work-related injury or illness.
Informacion Importante sobre el Cuidado Medico si tiene una Lesion o Enfermedad Relacionade con el Trabajo – Este panfleto contiene información muy importante sobre su atención médica, en case que sufra una lesión o enfermedad relacionada con el trabajo.
Complete Packet for Injured Worker (please print dual sided and return completed forms to Michelle McKay in Human Resources)
New Hire Pamphlet - If a work injury occurs