Workers' Compensation


The University is required by law to offer medical treatment to employees who claim a work-related injury or illness; determination of the cause of injury is made by a doctor (and/or investigation). When an employee informs you that they are injured or ill and believe it is work-related, provide them with a Workers’ Compensation Claim Form and a Authorization Form so that they can receive medical attention. Complete the Manager’s Report of Injury/Illness and submit it to the Workers' Compensation Coordinator within 24 hours of your notice.  More details on these important steps are provided below. 

Medical Emergency

  • In the event of a medical emergency, dial 9-1-1 from any campus phone to contact University Police.
  • If you are calling from a cell phone, dial the University Police Department directly at (909) 869-3070.
  • The campus police dispatcher will send the appropriate personnel to the site.
  • Some examples of medical emergencies are: excessive bleeding, broken bones, loss of consciousness, difficulty breathing, and severe chest pain.
  • When in doubt about the severity of a medical emergency, always dial 9-1-1 from any campus phone to contact University Police, and have the first responders assess the injured employee.

For medical situations that do not require an emergency response, provide the employee with a Authorization Form signed by you; then direct the employee to the preferred Industrial Clinic:

  • Pomona Valley Health Center - La Verne Location
    2333 Foothill Blvd Ste C La Verne, CA 91750
    Phone: (909) 536-1493
    Clinic Hours: Monday- Friday 8:00 a.m. to 8:00 p.m. Weekends & Most Holidays 9:00 a.m. - 5:00p.m.

  • Pomona Valley Health Center - Chino Hills Location
    3110 Chino Ave #150B Chino Hills, CA 91709
    Phone: (909) 630-7490
    Clinic Hours: Monday - Friday 8:00 a.m. - 8:00 p.m. Weekends & Most Holidays 9:00 a.m. - 5:00 p.m.

  • Pomona Valley Health Center - Claremont Location
    1601 Monte Vista Ave Claremont, CA 91711
    Phone: (909) 865- 9977
    Clinic Hours: Monday - Friday 8:00 a.m. - 8:00p.m. Weekends & Most Holidays 9:00 a.m. - 5:00 p.m.



On the date of injury or first date of treatment, if the employee is unable to drive themselves to the clinic, Pomona Valley Health Center will arrange for transportation by taxi to their facility. The manager can contact the Pomona Valley Health Center clinic directly to request taxi service or call Workers' Compensation at (909) 869- 3725.  Employees are responsible for their own transportation to attend follow-up medical appointments.

State law requires that a Workers’ Compensation Claim Form be provided to an employee within one (1) working day of an employer’s notice or knowledge of a work-related injury or illness.  Supervisors should follow these steps to meet required timelines and avoid fines/penalties being assessed to your department.

Step 1:
Ensure that the injured employee receives medical attention.
(See "Referring the Employee for Non-Emergency Medical Evaluation and Treatment" above)

Step 2:
Provide employee with a Workers’ Compensation Claim Form.  State law requires this form be provided to an employee within one (1) working day of an employer’s notice or knowledge of a work-related injury or illness.
(In the case of a medical emergency, Workers' Compensation will mail the form to their home.)

Step 3:
Call Workers' Compensation at (909) 869-3725 immediately to report the injury/illness.

Step 4:
Complete the Manager’s/Supervisor's Report of Injury of Illness and submit it to Workers' Compensation within 24 hours.

Submit forms via our Secure Workers’ Compensation Submission Form (an OnBase/PolyDoc form), sealed inter-office mail (marked as Confidential), or in person within 24 hours of the supervisor’s knowledge. Do not email or fax any documents that contain Social Security numbers or any other personally identifiable information. 


If hazardous conditions exist, immediately contact University Police and Environmental Health & Safety.

If defective equipment appears to be involved in the injury of an employee, the supervisor should immediately remove it from service and tag the equipment for identification (if applicable).

All claims of injury/illness require a medical assessment by a physician and documentation indicating the employee’s Return to Work status. There are three types of determinations:
  • Return to Work Without Restrictions: the employee is released to return to work without any restrictions and can be expected to perform the full-scope or usual and customary duties of their job without modification.
  • Return to Work With Restrictions: the employee is released to return to work with temporary restrictions to their physical activity. If a temporary medical restriction impacts the employee’s ability to perform their usual and customary job duties, the Manager/Supervisor must determine if modified or alternate work is available.
    • If work within the prescribed restrictions is available, the Manager and employee meet to discuss and complete a Transitional Employment Plan provided by Workers' Compensation. This step documents prescribed restrictions and the temporary modified assignment.
    • If modified/alternate work is not available, the employee has a status of Off Work and will meet with Workers' Compensation and Payroll to discuss the disability benefit options.
  • Off Work: the employee is not medically able to return to work for a specific period of time. The employee’s progress will be followed by a physician at regular intervals. Workers' Compensation and Payroll will meet with the
    employee to discuss the eligible disability benefit options.

The employee’s injury/illness may require repeat visits to the industrial clinic or other designated medical facility for treatment. Beyond the initial medical visit, employees are required to use sick leave credits for follow-up treatment and/or therapy.

Managers are encouraged to set clear expectations with both non-exempt and exempt employees regarding how medical appointments are to be managed in order to meet the operational needs of the department.

Employees are expected to keep their managers informed in regard to ongoing work restrictions.  If an employee is placed off work as a result of their injury, Workers' Compensation and Payroll will review with the employee eligible disability benefit options. Workers' Compensation will work with the department manager in coordinating the return to work process.

Please contact the Workers' Compensation Coordinator for assistance or if you have any questions about work-related injuries or illnesses.

Telephone:  (909) 869-3725