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WORKERS' COMPENSATION


Manager/Supervisor Responsibility



Injured Worker Declines Medical Treatment



Forms required:
(1)   Supervisor's Report of Accident, S&T 202   - NCR Form
(2)  Employee Request for Medical Treatment, S&T 201  - NCR Form

  • Step 1: Upon notification of an injury or illness, a Manager or Supervisor must complete both a “Supervisor’s Report of Accident” ( S&T 202) form and an “Employee Request for Medical Treatment” ( S&T 201 ) form. The “Supervisor’s Report of Accident” ( S&T 202 ) form should:
    • Include a detailed description of the accident
    • Be completed within 24 hours of the accident


  • Step 2: Offer the injured/illness worker immediate medical treatment


  • Step 3: If the injured worker declines medical treatment the injured worker must sign and date the “Employee Request for Medical Treatment” ( S&T 201 ) indicating, “I have declined the offer of professional medical treatment at this time”


  • Step 4: File the “Employee Request for Medical Treatment”( S&T 201 ) form along with the “Supervisor’s Report of Accident” ( S&T 202 ) form in the departmental personnel file.


  • Step 5: Inform the injured worker should they seek medical treatment at a later date, they are to inform their Manager/Supervisor immediately.

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Human Resources Division

44 North San Joaquin Street
Third Floor Suite 330
Stockton, CA 95202
Phone: (209) 468-3370
Fax: (209) 468-0508