Open EnrollmentFiscal Services - College of Marin Athletics 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Injured Worker' clearly at the top of the form. This is essential for identifying the individual involved.
3. Next, indicate whether the injured worker is a 10 or 12-month employee by selecting the appropriate checkbox.
4. Fill in the 'Regular Work Days' and 'Regular Work Hours' to provide context about the employee's schedule.
5. Input 'Total Weekly Hours' and 'Employee’s Salary' to give a complete overview of their employment status.
6. Answer whether the employee's salary is being continued during their absence, and provide details on their job title and last date worked.
7. Respond to questions regarding payment on the date of injury, claim form provision, and reporting of the injury.
8. Address safety hazards involved in the incident and whether they have been corrected, along with any potential for subrogation or third-party recovery.
9. Finally, confirm if modified duty can be accommodated and note when the employee returned to work, specifying if it was full or modified duty.

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