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December 15, 2003 Page 1 of 3 Administrative Guide Memo 25.6Stanford University

Accident and Incident Reporting

Authority

This procedural Guide Memo was approved by the Director of Risk Management.

Summary

This Guide Memo lists forms needed to fulfill federal and state requirements concerningaccidents, incidents, or exposures to employees in the workplace. It does not cover mental stressclaims; contact your local human resources officer immediately for guidelines on such claims.Stanford Linear Accelerator Center (SLAC) currently applies the applicable policies containedherein. SLAC employees must report accidents, incidents or exposures to SLAC MedicalDepartment.Section headings for this Guide Memo are:1. BENEFITS BROCHURE2. WHERE TO OBTAIN FORM3. REPORTS REQUIRED FOR EVERY INJURY4. REPORT REQUIRED WHEN A DOCTOR IS SEEN5. ADDITIONAL REPORT WHEN MEDICAL ASSISTANCE IS NEEDED OR ONE OR MOREDAYS ARE LOST FROM WORK6. WORKERS' COMPENSATION LOST TIME REPORT

1. BENEFITS BROCHURE

Detailed information about Stanford University Workers' Compensation benefits is available online athttp://www.stanford.edu/dept/Risk-Management/docs/workcompben.shtml

2. WHERE TO OBTAIN FORMSFormNo.Title Source

Cal-OSHAForm5020Employer's Report ofIndustrial Injury

http://www.stanford.edu/dept/Risk-Management/docs/forms/5020.html

DWCForm-1Employee's Claimfor Workers'CompensationBenefitsRisk ManagementSU-16 Workers'Compensation LostTime Report

http://www.stanford.edu/dept/Risk-Management/docs/forms/su-16.fft

SU-17 Accident/Incident/Exposure Report

http://www.stanford.edu/dept/Risk-Management/docs/forms/su-17.html

-- Employee Personal Physician Pre-Designation Form

http://www.stanford.edu/dept/Risk-Management/docs/forms/predesig.html

December 15, 2003 Page 2 of 3 Administrative Guide Memo 25.6Stanford University

3. REPORT REQUIRED FOR EVERY INJURY

In the event of an employee accident, incident or exposure, the injured or exposed person's supervisor mustcomplete and submit an Accident/Incident/Exposure Report (Form SU-17). As well as complying withstate and federal reporting requirements, prompt submission of Form SU-17 enables Environmental Healthand Safety to implement thorough accident investigations in order to remedy work-related hazards.Nonemployee accidents also require an SU-17.

a. Time Limit —

The SU-17 must be submitted within 24 hours of the occurrence.

b. Applicability —

The SU-17 applies to all employees (full-time, part-time and temporary), as well as toall students, contractors and visitors on campus, whether or not the injured or exposed person receivedmedical attention.

c. Who Signs? —

The SU-17 must be accurately completed and signed by both the injured or exposedparty and his or her supervisor. If the injured or exposed party is not a Stanford employee, thesupervisor or manager responsible for the area where the injury, incident, or exposure occurred shouldsign the SU-17. Should it be difficult to obtain the injured or exposed party's signed portion,departments should submit the supervisor's statement immediately, and the injured or exposed party'sstatement as soon as it is available.

d. Where to Submit —

Mail or deliver the original and two copies to Risk Management, 651 Serra Street,Room 250, mailcode 6207, along with Cal-OSHA Form 5020 if needed (see section 5 below). Retain onecopy for department files.

4. REPORT REQUIRED WHEN A DOCTOR IS SEEN

An Employee's Claim for Workers' Compensation Benefits (DWC Form 1) must be given immediately to theemployee along with the current year Workers' Compensation benefits sheet when a doctor is seenconcerning the injury, incident or exposure. Failure to comply with the state requirements may imposesignificant fines and penalties, which would be charged to the appropriate department. The DWC Form-1and a detailed instruction sheet are available from Risk Management, 651 Serra Street, Room 250,mailcode 6207, phone 650/723-7400.

a. Time Limit —

The DWC Form-1 must be signed by a University representative and then given ormailed to the employee within 24 hours of the accident, incident or exposure.

b. Applicability —

The DWC Form-1 applies to all employees (full-time, part-time and temporary) whenthe injured or exposed person receives medical attention.

c. Who Signs? —

The employer/supervisor/administrator signs the employer section. The injuredperson is not required to sign.

d. Where to Submit —

A copy of the form must be sent to Risk Management for verification of employerobligation.

5. ADDITIONAL REPORT WHEN MEDICAL ASSISTANCE IS NEEDED OR ONE OR MORE DAYSARE LOST FROM WORK

State law requires that an Employer's Report of Industrial Injury (Cal-OSHA Form 5020) be submitted whenan industrial injury or occupational disease results in:• lost time beyond the day of injury, or• medical treatment by a physician in a clinic, hospital, emergency room, or medical office.Cal-OSHA Form 5020 is required for payment for medical services and is the basis for any disability claimunder Workers' Compensation Insurance. See Guide Memo 22.6, Sick Leave and Other Paid DisabilityLeave,http://adminguide.stanford.edu/22_6.pdf

,concerning absences due to work-connected disabilitiesand medical coverage under Workers' Compensation Insurance.