Stanford University

Risk Management Department

5020 Employer's Report of occupational Injury or Illness

NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness whcih results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury/illness, or death must be reported immediately by telelphone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

This form must be typed. You may download either:

  • A printable version in PDF format. You will need Adobe's Acrobat Reader.


  • A Word version. When you use this form you will fill it out inside Word, then print it to have it signed and submitted. * Do not save document onto your computer. It contains confidential information that must not be stored.

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

Risk Management, Mail Code: 6207, 723-7400
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