| Oakland Police Department Medical Resource Site Forms |
|---|
Declination of Medical Treatment ("On the Spot") |
| When you sustain an injury at work and you only want to document the injury or receive a single doctor's visit to evaluate the injury, you make complete the Declination Packet, formerly known as "On the Spot Injury." |
| It is important to document all work–related injuries even if you are not going to lose any time from work. If at a later date you experience any pain or need further medical treatment, you will need to complete an Initial Injury Packet, and the Declination will serve as your documentation for the original injury. |
| The Declination Packet consists of the following documents: |
| Cover Sheet |
| Employee Incident Report |
| Supervisor Incident Report |
| Initial Injury Packet |
| When you sustain a work–related injury that requires either hospitalization or home rehabilitation requiring you to lose time from work, you must complete and submit the Initial Injury Packet within 24 hours of the date of the injury. |
| NOTE: You do not need the entire packet complete to submit it to the Medical Office. The minimum the law requires for you to receive a claim number is the DWC-1 and the 5020. However, all documents are required for approval. |
| An injured employee may receive up to $10,000 in medical treatment during the approval process, so send what you have right away. We will help you get the rest complete. |
| Instructions: This is a printed document of the detailed instructions for completing and submitting the Initial Injury Packet. |
| DWC–1: The DWC–1 is the state–mandated form required for all Workers Compensation claims. The Employees Section can only be completed by the employee. |
| 5020–Supervisor: The Supervisor must complete this form. The employee can not complete or sign in the Supervisor's absence. |
| Employee Incident Report: The employee completes this form documenting the events leading up to the injury, the injured body part, and other requested details. The employee must sign and date this form. If the employee is unable to complete this form, leave it blank and the Medical Office will contact the employee at a later time. |
| Supervisor Incident Report: The Supervisor completes this form. You may use the Employee Incident Report as a reference for dates and times. It is common for the Supervisor not to be present at the time of injury, and completion of the form is not an admission of liability. |
| Medical Release Form: The employee completes, signs, and dates this form. The Medical Release Form only releases information related to the injured body part. |
| Treatment Authorization: This form is for authorization of the City Physician when the Medical Office is closed. If the employee has a copy of his/her Predesignation Form, the employee may go to that doctor. If the employee does not have a copy of his/her Predesignation Form, the employee must go to the City Physician and request a referral. |
| Mileage Reimbursement: Should you incur any expenses while traveling to and from medical appointments, you may complete this form and submit it to JT2 for reimbursement. |
| Clinic Information: Directions and Office Hours of the City Physician. |
| Transitional Assignment Request Form |
| The Medical Office is building a job bank, which is a detailed listing of all jobs and tasks throughout the Police Department to which members and employees may be assigned for a transitional period while recovering from work–related injuries. If you have a job task, you may click on the link below, complete the form, and submit it to the Medical Office. |
| Family Medical Leave |
| Times occur when you may need extended time away form work due to a personal or immediate family member's illness. In those circumstances, it is recommended that you complete a Family Medical Leave Application. Both the Family Medical Leave Act and the California Families Right Act provide protections to employees caring for either themselves or immediate family members. |
| Family Medical Leave Application |
| Medical Verification |
| Leave Request Memo Template |
