EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS SCIF E3067 (STATE) FORM - 2581.3

State Fund must receive the employer’s report within five calendar days of the employer’s knowledge or notification that a work-related injury or illness has occurred. The form must be submitted in the following situations:

• A work-related injury or illness results in lost time beyond the date of injury or medical treatment beyond first aid;
• An employee presents a doctor’s note stating an injury or illness is or may be work related;

  or

• A completed Claim Form (DWC 1) is received from either the employee, their doctor, their attorney or State Fund

For instructions on how to complete and submit this report, please see the publication Workers’ Compensation Claim Kit, Instructions for Completing the Forms Required to Report a Work-Related Injury or Illness on the California Department of Human Resources website: https://www.calhr.ca.gov/Documents/claim-kit.pdf