Risk Management Forms
County Employees Only
Injury Management/Workers Comp
- Injury Management Checklist
- 1 - Incident Only Injury with Declination Form
- 2 - First Aid Packet-Dr Ltr-Workability-Dr Release-Temp Prescriptn
- 3 - Work-Comp Packet-Mileage Reimburs-Info Pamphlet
- Supervisor's Injury Investigation Form
Incident Hazard Reports
Reporting Incidents and Accidents
Report Within 24 Hours
Incidents and accidents (vehicle and property or liability) are to be reported to the risk manager by the designated responsible employee, supervisor, or department head as soon as possible (within 24 hours) to ensure timely investigation, claims management, and correction of hazardous conditions to prevent additional injury, damage, or loss.
Job-Related Injuries or Illness
All employee job-related injuries or illnesses are to be reported immediately (within 24 hours). Occupational Safety and Health Administration (OSHA) standards require the county to report serious injury (loss of limbs or fatality) within eight hours time.
Notify supervisors, department heads, and the risk manager by phone. Leave a message on voice mail if you are unable to reach these persons via office line or cell number. Accident reports are to be sent immediately, by fax if necessary, to the risk manager at (530) 283-6288. The accident report is to be filled out completely and the appropriate workers' compensation paperwork will need to be submitted. We are penalized for late reporting. Your cooperation with these procedures is crucial for cost savings on claims.
In Case of Emergency
For More Information
If you have any questions or would like more information, please contact the Risk Management Department at (530) 283-6315.
- Injury Management Program Claim Reporting Checklist (PDF)
- Notice to Doctor Regarding First Aid Treatment (PDF)
- Plumas County Incident/Hazard Report (PDF) (Internal Use ONLY!)
- Work Ability Form (PDF)
- Facts About Workers' Compensation Injury Management Program (PDF)
- First Fill Information - Trindel Insurance Fund (PDF)
- Declination of Medical Treatment (PDF)