Employee Resources
If you are a Cal Poly Pomona state employee, student assistant, or volunteer who has sustained an injury or illness that you feel was caused by your work, there are three steps to report your injury or illness and obtain medical evaluation and treatment. Please contact the Workers' Compensation Coordinator via email or call 909-869-3725 for assistance or if you have any questions about work-related injuries or illnesses.
Step #1: Notification
- Inform your supervisor immediately if you sustain a work-related injury or illness.
- Medical Authorization Form: Your supervisor will sign and provide you with this form for non-emergency medical evaluation and treatment and refer you for medical treatment at the University's designated industrial medical clinic for evaluation and treatment.
- Personal Physician Pre-Designation Form: If you have a current Personal Physician Pre-Designation Form on file with Cal Poly Pomona's Workers' Compensation, you may go to your personal physician for evaluation of your work-related injury or illness. Please note that this form must be on file prior to the injury/illness and include the current personal physician's agreement to treat for work-related injuries/illnesses. Contact the Workers' Compensation Coordinator via email or call 909-869-3725 to verify a current pre-designation is on file.
- Manager's Report of Injury/Illness Form: Work with your manager to complete this form.
- Workers' Compensation Claim Form (DWC1): If a work-related injury or illness requires more than first aid treatment, your manager or supervisor should provide you with a Workers' Compensation Claim Form. Complete and sign the employee portion of this form as it initiates the claim process and protects your rights.
Submit forms via one of the following methods:
- Secure Workers’ Compensation Submission Form (an OnBase/PolyDoc form)
- Sealed inter-office mail (marked as Confidential)
- In-person within 24 hours of the supervisor’s knowledge at the HR Customer Service Center in the Student Services Building 121, Second Floor
Once your claim form and your manager's reporting forms have been received by the Workers' Compensation Coordinator, a claim will be submitted by us to the University’s Workers’ Compensation Claims Administrator at Sedgwick Claims Management Services (CMS). In addition to receiving a call from us, an account representative of Sedgwick CMS will contact you and ask questions about your injury/illness.
View the Pharmacy Locator, Refill-Too-Soon, and Home Delivery Guide from Optum to provide helpful information.
General Inquiries
Hours: 8:00 AM - 5:00 PM I Email: hrscsc@cpp.edu I Phone: 909-869-3733
3801 W. Temple Ave, Pomona, CA 91768
Student Services Building 121, Second Floor
Map and Directions to our office
Map and Directions to our office