Worker's Compensation Claim Form (DWC-1)

Please complete "Employee" Section and return to Human Resources 

Employee's Report of Work-Related Injury/Illness

Please complete within 24 hours after an injury/illness occurs and return to Human Resources.

Supervisor's Report of Work-Related Injury/Illness

All injuries/illnesses must be reported.  Supervisors must complete this report IMMEDIATELY UPON NOTIFICATION of an on-the-job injury/illness and return to Human Resources.

What is Worker's Compensation?

If you are injured or become ill because of your job, you may be entitled to Workers' Compensation Benefits. The Workers' Compensation Program at California State University, Maritime Academy will pay the cost of all (reasonable) medical and hospital bills necessary to treat you for a work-related injury. An injury or illness can be caused by an event such as a slip and fall or by repeated exposure over time, such as repetitive keyboarding.

Incident Notification

As a means of a continuous improvement strategy, all incidents, regardless of magnitude, are to be immediately reported to Department leadership, Human Resources, and the Department of Safety and Risk Management. An incident is defined as any unsafe behavior or condition, any property damage, any spill to the environment, a self-treated first aid, a self-transported medical treatment or serious event requiring emergency services.

Anytime a safety incident occurs, Prompt Reporting is CRITICAL to:

  • Ensure any/all injured persons are cared for properly.
  • Identify the system failure and improve components. (Process management and training elements)
  • Lessons Learned: Prevent similar events from reoccurring.
  • Satisfy all compliance recordkeeping

NOTE: The University will not be responsible for payment of workers' compensation benefits for an injury that occurs from your voluntary participation in any off duty, recreational, social or athletic activity that is not part of your regular work duties.


Notice of Pre-Designation of Personal Physician (Work-Related Injury/Illness)

In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

  • on the date of your work injury you have health care coverage for injuries or illnesses that are not work-related;
  • the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;
  • your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries;
  • prior to the injury your doctor agrees to treat you for work injuries or illnesses;
  • prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify the Benefits and Workers' Compensation Unit if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

Workers' Compensation Contact

If you have any questions concerning Workers' Compensation benefits or forms, please contact the on-campus Workers' Compensation Coordinator, Kristen Bautista, at (707) 654-1146 or

Other Contacts:

Craig Dawson, Environmental Health & Safety Manager
Phone: (707)654-1076

Cal Maritime Police Department
Emergency, on Campus: 911
Non-Emergency: (707) 654-1176

Sedgwick CMS (Third Party Administrator for CSU Workers' Compensation Program)
PO Box 14629
Lexington, KY 40512
Phone: (866) 766-1115

Eddy Canavan
Worker's Compensation Consultant
Phone: (714) 403-2978

Occupational Safety and Health Administration

California State University Risk Management Authority

State of California, Department of Industrial Relations

California Workers' Compensation Institute

Time of Hire Notice

Predesignated Personal Physician

Notice of Personal Chiropractor/Personal Acupuncturist

Visit the State of CA Division of Worker's Compensation for additional forms