24-103 Work-Related Injuries, Illness Reports and Medical Treatment Locations

All work-related injuries and illnesses requiring medical attention shall be reported to the Medical Liaison Unit. The required forms, available in the SFPD Forms folder, must be completed whenever professional medical care is necessary for an occupational injury or illness, toxic/infectious exposure or needle stick.

The investigation of an occupational illness or injury is the responsibility ofthe member's immediate supervisor and shall be conducted immediately after the injury or illness is reported. The member's immediate supervisor, not the member, shall prepare and sign all forms and submit the forms directly to the Medical Liaison Unit within twenty-four hours of learning of the illness or injury. To avoid delay, commanding officers should send the forms directly to the Medical Liaison unit, once approved. The injured member shall call the CCSF Injury Reporting Hotline at 1-855-850-2249 to receive advice and treatment. If the member is unable to make the call, the member's immediate supervisor shall make the call on behalf of the injured member. Commanding Officers shall ensure that the supervisor's investigation is complete. All paperwork shall be faxed to the Medical Liaison Unit at (415) 837-7243 and then sent through Department mail to Medical Liaison.

When a member has suffered a serious injury or illness or is hospitalized, the member's immediate supervisor shall notify the Medical Liaison Unit. The Medical Liaison Unit hours of operation are Monday through Friday, 0800-1700 hours (415) 837-7222. Notify the Department Operations Center after 1700 hours and on weekends. The Medical Liaison Unit is responsible for processing the claims with the Worker's Compensation Division.

HRMS
If a member suffers a work-related injury or illness:

• Do not enter the member into HRMS as DP.
• A member must use SP (or other personal time) until the claim is accepted by Worker's Compensation.
• Medical Liaison will notify the member's detail and notify SFPD Payroll Division when a member's claim is accepted by Worker's Compensation.

If a member has returned to work or has been placed on temporary modified duty, contact the Personnel Sergeant (415) 837-7220 to ensure proper assignment.

New Injuries and Illnesses 
The following forms shall be completed when documenting a new work-related injury and/or illness:

• State ofCalifornia Employer's Report of Occupational Injury or Illness, Form 5020 (Rev. June 2002). This form must be typed and signed by the immediate supervisor, not the injured member.
• Employee's Claim for Workers' Compensation Benefits, Form DWC-1 (Rev. 01/16). The employer must give the DWC-1 form to the member within 24 hours of the notice of illness/injury. (Send to the member by mail if the member is not available.)
• Supervisor's Investigation of an Illness/Injury, SFPD-439 (02/97). The supervisor should not fill out the member's section.
• Injured member's memorandum. This report is prepared by the injured member or immediate supervisor if the member is incapacitated.
• Physician's medical report, if available.

Recurrence of Previously Reported Injuries or Illnesses 
DOCUMENTATION ONLY (NO MEDICAL TREATMENT) 
Work-related injuries or illnesses that are for documentation purposes only require: (1) the Supervisor's Investigation of an Illness/Injury, SFPD-439 (02/97); and (2) a memorandum from the injured member.

Non-Industrial Injuries, Illnesses and Medical Conditions 
When a member requests temporary modified duty because of a non-industrial injury; illness; or medical condition, supervisors shall complete the Supervisor's Investigation of an Illness/Injury, SFPD-439 (02/97). The Deputy Chief of the Administrative Services Bureau will review the request for temporary modified duty in accordance with the procedures in Department General Order 11. 12.

Treatment 
All members who sustain a work-related injury or illness shall initially seek treatment at one of the following clinics, regardless of having a Pre-designation ofPhysician form (DWC 9783) on file with the Department. After this mandatory initial visit, members who have a Pre-designation form on file shall contact the Workers' Compensation Division at (415) 701-5800, or the Medical Liaison Unit (415) 837-7220 for authorization before seeking treatment with their own physician.

All members who sustain a work-related injury or illness during business hours shall use one of the following facilities for treatment:

SFO Medical Service at SF Airport, International Terminal, Level 3, "A" side 
Hours are 7:00 a.m. to 7:00 p.m. Monday through Friday 
Telephone: (650) 821-5600

Kaiser Permanente Occupational Medicine Clinic (Opera Plaza) 
601 Van Ness Avenue, Suite 2008 (Mezzanine) 
Hours are from 8:30 a.m. to 5:00 p.m., Monday through Friday 
Telephone: (415) 833-9600; free valet parking available.

Sutter Pacific Medical Foundation-Davies Campus, Occupational Medicine Clinic 
Castro and Duboce Streets, Rm. #160 A Level, South Tower 
Hours are from 8:00 a.m. to 4:30 p.m., Monday through Friday 
Telephone: (415) 600-6616

Saint Francis Memorial Hospital 
Workers' Compensation Clinic 1199 Bush St #160 (located next door to the Emergency Department) 
Hours are from 7:30 a.m. to 5:00 p.m., Monday through Friday 
Telephone: (415) 353-6305

St. Francis Health Center at AT&T Park 
24 Willie Mays Plaza 
Hours are from 7:30 a.m. to 5:00 p.m., Monday through Friday 
Telephone: (415) 972-2249

Stanford Health Care - ValleyCare Occupational Health 
4000 Dublin Blvd, Suite 150, Dublin, CA 
Hours are from 8:00 a.m. to 5:00 p.m., Monday through Friday 
Telephone: (925) 416-3562

Sonora Regional Medical Clinic, Job Care 
19747 Greenley Rd. Suite 2, Sonora, CA 
Hours are from 8:00 a.m. to 4:30 p.m., Monday through Friday 
Telephone: (209) 536-3780

Concentra Occupational Health - Brentwood 
3140 Balfour Road Suite C 
Brentwood, CA 94513 
(925) 626-3801 
(925) 626-3850 (Fax) 
Monday - Friday 8:30 a.m. to 5:00 p.m.

Concentra Occupational Health - Gilroy 
190 Leavesley Road Suite 102 
Gilroy, CA 95020 
(408) 848-0444 
(408) 848-0443 (Fax) 
Monday - Friday 8:30 a.m. to 5:00 p.m.

Concentra Occupational Health - Milpitas 
1717 S. Main Street 
Milpitas, CA 95035 
(408) 957-5700 
(408) 946-5476 (Fax) 
Monday - Friday 8:30 a.m. to 5:00 p.m.

Concentra Occupational Health Santa Rosa 
1221 N. Dutton Avenue 
Santa Rosa, CA 95401 
(707) 543-8360 
(707) 543-8361 (Fax) 
Monday - Friday 8:30 a.m. to 5:00 p.m.

St. Mary's Hospital is not a Workers' Compensation authorized treatment facility.

All members who sustain a work-related injury or illness after business hours shall use one of the following facilities for treatment:

Zuckerberg San Francisco General Hospital Emergency Department 
1001 Potrero Avenue 
Telephone: (415) 206-8111

Sutter Pacific Medical Foundation-Davies Campus Emergency Department 
Castro and Duboce Streets 
Telephone: (415) 600-6600 
Parking is available in the adjacent garage

Kaiser Permanente Medical Center 
Report to Injury Center from 5 :00 p.m. to 9:00 p.m. 
2238 Geary Blvd., 3rd Floor 
Telephone: (415) 833-2291

Report to Kaiser San Francisco Emergency Department after 9:00 p.m. 
2200 O'Farrell Street at Baker Street 
Telephone: (415) 833-2000 
Parking is available in the adjacent garage.

Saint Francis Memorial Hospital Emergency Department 
900 Hyde Street, between Pine and Bush Streets 
Telephone: (415) 353-6300 
Parking is available at 1234 Pine St., 909 Hyde St., and 1199 Bush St.

Sonora Regional Medical Clinic 
1000 Greenley Road, Sonora, CA 
Telephone: (209) 532-3161

/s/
WILLIAM SCOTT 
Chief of Police

Per DN 23-152, all sworn & non-sworn members shall electronically acknowledge this Department document in PowerDMS within (30) thirty calendar days of issuance. Members whose duties are relevant to this document shall be held responsible for compliance. Any questions regarding this policy should be sent to [email protected] who will provide additional information.