Fairfield, CA
Home MenuInjuries & Workers' Compensation
Injured on the Job? See the forms/resources below:
| Form | Description |
| The Facts About Workers' Compensation | Information about worker's compensation. |
| Information for employees seeking help for a recent injury or illness. | |
| Supervisor Checklist | Checklist for completing a WC packet. |
| Department of Worker's Compensation Form 1 (DWC-1)* |
Required form for supervisor to give directly to injured employee. |
| Supervisor Report of Accident/Injury* | Supervisor is to complete this form and forward to workerscomp@fairfield.ca.gov. |
| Medical Service Order | To be given to injured employee before seeking medical treatment. |
| Medical Service Order (Public Safety Psychological Injury only) | To be given to injured employee before seeking treatment for psychological injury. This version of the MSO applies only to sworn and limited non-sworn classifications in public safety. |
| Prescription First Fill Form | Temporary Rx card to ensure injured workers can fill their initial prescription for a work-related injury. |
| Pre-Designation Form | This form must be completed and turned in to HR BEFORE an injury occurs to be valid. |
| Instructions for Supervisors and Managers to Report Hospital Admissions to HR/CalOSHA | Instructions for supervisors to notify HR/CalOSHA of Hospital Admissions in connection with employment |
|
Refusal of Medical Treatment for Work-Related Injury Note: This form requires Adobe Acrobat for e-Signature |
Acknowledgement form to be signed by employee who refuses medical treatment but requests or is ordered to leave work. |
*Supervisors are required to complete these forms and send them to Human Resources (workerscomp@fairfield.ca.gov) immediately upon knowledge of an injury.
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