To be completed and submitted to Workers’ Compensation Office within 24 hours of report of injury. (Please use separate sheet of paper if additional space is needed
Has This Employee Been Placed on Warning For The Following
Supervisor’s Follow-Up (must be completed within 10 days of injury/illness)
Rev. 10/11 Fax and send original to Workers’ Compensation Office: Fax 925-680-2505 1 copy to be retained at site