Due Date: First Day of Class

While working in the hospital and on the ambulance as part of this course you are covered by COC's Worker's Compensation Program. That means if you get hurt during a clinical shift, COC will send you to a Worker's Compensation doctor and treat you for free, and cover your bills if you are treated in an emergency room. You can choose to be treated by your own doctor instead, but they must agree to it in advance by signing page 2 of the Designated Physician form. This must be done by Week 1 of the course.

Step 1
- Use a computer, not a phone or a tablet
  - Students can use free computers at the COC TLC or Library on both campuses and can print for free using the Wepa app.

Step 2
- Download and save the form to the computer's desktop
- Open the form from the desktop
- Fill out page 1:
  - Employee Name: Type in your LAST NAME, FIRST NAME
  - Address: Type in your FULL home address, including city, state, and zip code
  - IMPORTANT: ONLY CHECK THIS BOX If you want to be covered by COC's Worker's Compensation (free)
    - Check the box next to "I acknowledge receipt of this form and elect not to predesignate my personal physician..."
  - Employee Signature: May be digitally signed, or hand-signed after printing
  - Date: Use the dropdown to select today's date
- IMPORTANT: ONLY FILL OUT PAGE 2 of the form IF YOU ARE DECLINING WORKER'S COMP AND YOUR OWN PHYSICIAN AGREES TO COVER YOU FOR WORK-RELATED INJURIES
  - If you are declining worker's comp, check the box next to "If I am injured on the job, I wish to be treated by my personal physician..."
  - Name of Physician or Medical Group: Type in the name of your doctor
  - Phone Number: Type in your doctor's phone number
  - Address: Type in your doctor's address
  - Name of Insurance Company, Plan, etc.: Type in your insurance company's name
  - Employee Signature: Digitally sign or hand-sign after printing
  - Date: Use the dropdown to select today's date
  - Take it your doctor to stamp and sign - This must be done by Week 1

- Print the form and use a paperclip to attach it to Checklist 1 in the order shown on the checklist