State of California

M E M O R A N D U M


To:       PERSONNEL MANAGEMENT LIAISONS                 Date: July 7, 1993
                                              Reference Code: 93-42

          THIS MEMORANDUM SHOULD BE DISTRIBUTED TO:

          ALL DEPARTMENTAL PERSONNEL OFFICERS
          HEALTH & SAFETY & RETURN TO WORK COORDINATORS

From:     Department of Personnel Administration
          Workers' Compensation and Safety Program


Subject:  Employer's Report of Occupational Injury or Illness
          SCIF 3067 (REV.2-93) STATE

          State Compensation Insurance Fund (SCIF) has released the revised
          Employer's Report of Occupational Injury or Illness, SCIF 3067 (REV.2-
          93) STATE.  The old forms are no longer valid.  I apologize for the
          delay in forwarding this information to the Departments, however, the
          Department of Personnel Administration (DPA) did not receive notice of
          the revised form until June.

          Please note the form has several changes (see attachment).  Departments
          are instructed to complete these forms accurately.  This information
          will be used to track injury trends by agency, classification,
          bargaining unit and time of day.  In addition, it will allow the
          departments and DPA to concentrate on injury/illness prevention and
          claims management efforts where they are most cost effective.

          Changes as indicated by the item #:

          1.    Department = Include agency name
          1A.   P.A.C. or SCIF Policy Number = Agency Code
          3A.   Location Code = Department with-in an agency*
          4.    Nature of Business = Optional or N/A
          5.    State Unemployment Insurance Acct. NO. = N/A
          7.    CSID# = Agency/unit/class/position number (13 digit number)
          12.   CBID# = Collective Bargaining Unit
          14    Employment Status.  Self explanatory
          14A.  Employment Status Cont. = Status after the injury date
          14B.  Under What Class Code...assigned? = N/A
          16.   Other Payments.../Salary = Self explanatory
          18.   Military Time = 8:00 a.m. = 0800 or 1:00 p.m. = 1300
          19.   Military A.M or P.M = If using Military time N/A
          25.   Paid Full Wages...Worked = Self explanatory
          26.   Salary Being Continued? = Self explanatory
          27.   Date of Employer's Knowledge = Self explanatory
          28.   Date Employee Was Provided SCIF 3301 = Self explanatory
          31.   Department Where Event or Exposure Occurred = Self explanatory
          32.   Other Workers Injured/Ill = Self explanatory
          PML 93-42
          Page 2


          33.   Equipment, Materials and Chemicals... Self explanatory
          34.   Specific Activity... = formerly #16
          35.   How Injury/Illness Occurred = formerly #17
          38.   Was Another Person Responsible? = Self explanatory
          40.   Leave Credits for IDL Benefits.  Note: Prior to the new revision
                this was #29 - leave credits used in supplementing temporary
                disability benefits.  Use this section to indicate supplementation
                for IDL/TD benefits.

          *Departments that would like to add Division Codes to specify field
          locations, should contact John Holder, State Contract Consultant, State
          Compensation Insurance fund, Sacramento, CA, 916) 567-7559.

          If you have any questions, please contact Sondra Cooper at DPA, Workers'
          Compensation and Safety Program on either (916) 327-4021
          or CALNET 467-1839.






          Patricia Pavone, Chief
          Benefits and Training Division


          Attachment