Workers' Compensation Forms and Brochures

Welcome to the Workers' Compensation Forms & Brochures Page.  This is where County employees can find forms and brochures for all Workers' Compensation Programs.




Reference for Near Miss/No Injury Occurred, On the Job Injuries requiring medical treatment, and Deaths occurring while on the job
State mandated posting notice to be displayed in an area accessible to all employees
Brochure explaining your rights to workers' compensation benefits and how to obtain them.
Summary/Overview of Workers' Compensation

Pegasus Risk Management Medical Provider Network Information
English Version

Explanation of the Medical Provider Network (MPN) provided to all new hires and to all new workers' compensation claimants


Pegasus Risk Management Medical Provider Network Information Brochure
Spanish Version

Link to doctors within the Medical Provider Network


Time of Hire Pamphlet

Explanation of Workers' Compensation claims provided to all new hires


Predesignation Form

Employees who have health insurance may elect to designate their personal physician to treat them for an on the job injury or illness. The physician must agree in writing and the form must be completed and on file in prior to the date of injury


Occupational Illness/Injury Reporting Form Rev 3/22/13

Provide to employees who have been injured on the job and email or fax form to the CEO-Risk Management Division at moc.ytnuocnats@mdcs or 525-5779 within 24 hours of the notice of incident


DWC-1 Workers' Compensation Claim & Notice of Potential Eligibility

Provide to employees who have been injured on the job employee completes the first eight (8) lines of the form and submits to the CEO-Risk Management Division. CEO-RMD will complete the bottom half of the form and provide the employee with a copy of the completed document


DWC-1 Log

Department logs all DWC-1 forms provided and maintain this log in the department


Supervisor's Incident Investigation Report Rev 2/10

Supervisor to complete while investigation the new on the job injury/illness report submit form to the CEO-RMD within 48 hours of incident


Witness Statement 3/11

This form is optional and should be completed when the event was witnessed


Request for Medical Services

Provide to employees who have been injured on the job. Form can be used to authorize initial treatment. Form should be submitted to the CEO-RMD via email or fax


Authorization for Release and or Disclosure of Protected health and or Personal Information

HIPPA compliant authorization for the release of records to be provided to employees who have been injured on the job. Employee completes and signs the release and sends to CEO-RMD or directly to the Pegasus Claims Examiner.


Physician Report of Work Capacity 6/13

Optional form. Can be used by a physician to report any medically necessary temporary work restrictions. If medical facility has a similar reporting tool available, they may submit their own form in lieu of using the County form

To be used when a physician has provided the employee with a medical certification that includes the need for work restrictions. The employee and the department representative will meet to review the necessary work restrictions and determine if the department will be able to accommodate the restrictions on a temporary basis

Leave of Absence Request form 7/11/19

When physician has determined that, it is medically appropriate for an employee to be taken off work for a recuperation period. For additional information, refer to the Medical Leaves Policy and Procedures webpage.