Triad Local Schools Work Related Accident/Incident/Illness Reporting Procedures

Transcription

1 Last Edit: Triad Local Schools Work Related Accident/Incident/Illness Reporting Procedures 1. Employee must report the work related accident/incident or illness to his or her designated supervisor immediately. 2. Employee must obtain a copy of the Triad Local School Accident/Incident Packet from his or her supervisor. 3. Employee must complete the Accident/Incident Report. a. If no medical attention is required, employee is to fill out and return completed accident/incident report to supervisor. For an incident where no medical attention is sought, the process ends with this step. b. If medical attention is sought for work related injury or illness, please proceed with the rest of the packet. 4. Accident/Incident Report includes forms which need to be completed by employee, supervisor, and attending physician. The Work Related Accident/Incident or Illness flow chart explains the step by step procedure; however, if questions remain, employees are encouraged to call the Triad Central Office ( ) for assistance. 5. Employee must return all completed forms to his or her designated supervisor.

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3 Form to be completely filled out by Triad Local Schools Revised employee or employee s supervisor. ACCIDENT INCIDENT REPORT STAFF This form is either front to back (or 2 single sheets) BUILDING Date of Incident: Time of Incident: a.m. / p.m. Elementary Middle School NAME OF STAFF MEMBER INVOLVED: High School Street Address: City: Other: Telephone No.: Job Description: CHECK NATURE OF INJURY Abrasion Burn Cut/Laceration Possible Fracture Possible Sprain Bruise Head Injury Puncture Possible Dislocation Other: CHECK PART OF THE BODY INJURED (Indicate left or right side when applicable) FACE Eye L / R Ear L / R Nose Mouth Chin Tooth HEAD Forehead Scalp Front of Head Back of Head Side of Head L / R Neck TRUNK Chest Abdomen Upper Back Lower Back Rib(s) L / R Pelvis ARMS Shoulder L / R Upper Arm L / R Lower Arm L / R Elbow L / R Hand L /R Finger L / R LEGS Hip L /R Upper Leg L / R Lower Leg L / R Knee L / R Foot L / R Toe(s) L / R WHERE THE INCIDENT OCCURRED Athletic Field Grounds Parking Lot School Bus To or From School Cafeteria Gym Playground Sidewalk Vocational Shop or Lab Classroom Hallway Restroom Stairway Other: Name of person in charge when incident occurred: POST INCIDENT INFORMATION Was this person present when the incident occurred? Yes No Name(s) of any witness(es) or first person on the scene: Was first aid administered? Yes No If yes, by whom? If yes, give brief description: Was spouse or other responsible person notified? Yes No If yes, by whom? Time of day: a.m. / p.m. If no, explain: Was staff member sent home? Yes No Was staff member accompanied? Yes No Was he/she referred/taken to physician? Yes No If yes, by whom? Was he/she transported to hospital? Yes No If yes, by whom? If yes, name of hospital: Location: Complete Other Side EVEN IF THERE IS NO APPARENT INJURY

4 This form is either front to back (or 2 single sheets) 1. What exactly happened? INCIDENT STATEMENT 2. Who observed the incident (employee names, student names, etc.) 3. Who provided initial assistance and how quickly was this assistance provided? 4. Indicate who was on duty and if they were present. 5. At the time of the incident, was the employee was: behaving recklessly behaving prudently (and) not following school rules following school rules 6. Was equipment involved? Yes No If not, skip to question #7. If equipment was involved, was it in proper working order? Yes No If no, explain why faulty equipment was being used. Was the employee allowed to use the equipment and was he/she obeying the rules for the equipment? Yes No If no, explain: 7. Any other information related to this incident: 8. Could anything have been done prior to prevent this incident? What steps can be taken to prevent future incidents of this type? Signed by Reviewed by Employee Involved Date Witness Date Principal or Supervisor Date Superintendent Date Comments: Original filed in Board Office. Copies given to: Employee, Supervisor, Treasurer, PERRP Coordinator

5 Work Related Accident/Incident or Illness Flow chart and protocol for documentation and subsequent filing with BWC and OSHA. Last Edit: Employee reports accident/incident or illness to immediate supervisor and seeks appropriate medical attention. Employee receives Accident/Incident Packet from Immediate Supervisor IF Employee DID NOT require MEDICAL ATTENTION: Employee ONLY completes Accident/Incident Report and return it to Supervisor. IF Employee DID seek Medical Attention: Employee completes Accident/Incident Report and chooses one of the following statements to continue flow chart. ACCIDENT/INCIDENT PACKET INCLUDES: Accident/Incident Report Sick Leave Option FROI-1 TWP Notice BWC-3914 ability to return to work form CompManagement Information Transitional Work Program Satisfaction Survey PERRP 300P LOG - Principal to fill out PERRP 300AP SUMMARY Principal to fill out Employee is able to return to work with no lost time. Employee cannot return to work immediately due to the injury / illness Lost Time Claim Employee gives following forms to Principal / Superintendent: Accident/Incident Report FROI-1 PERRP 300P LOG - Supervisor to fill out PERRP 300AP SUMMARY Supervisor to fill out Employee gives the following list of forms to their immediate supervisor: Accident/Incident Report FROI-1 Sick Leave Option BWC-3914 Employee gives doctor letter concerning TWP Notice and BWC-3914 and MCO contact information sheet Accident/Incident Report to: Treasurer Superintendent Personnel File OSHA Coordinator Immediate Supervisor Principal / Superintendent distributes forms as follows: FROI-1 to: Treasurer Principal or Superintendent Superintendent Accident/Incident Investigation: After receiving accident/incident report from the immediate supervisor, the superintendent will conduct an independent investigation of the accident/incident or work related illness including review of the written report and interview of any relevant witnesses and take any action deemed appropriate. The findings of the investigation will be reviewed by the Triad Safety Committee. Principal / Superintendent sends Accident/Incident Report to: Treasurer Superintendent Personnel File OSHA Coordinator FROI-1, Sick Leave Option, BWC-3914 to: Treasurer Public Employee Risk Reduction Program LOG (PERRP300P) to: Appropriate supervisor Physician files BWC-3914 with MCO and gives copy to employee OR sends it directly to Triad Treasurer PERRP LOG and SUMMARY FORMS Principals fill out and send to superintendent by January 15 th of each year. Superintendent will then fill out District Summary Form.

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7 First Report of an Injury, Occupational Disease or Death This form can be completed and submitted online at ohiobwc.com Report your injury by completing all three sections of this form 1 2 Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the first visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section. The provider can then submit the FROI to the MCO. Deliver, mail or fax the completed document to your employer or your employer's managed care organization (MCO). 3 4 If you do not know your employer's MCO, contact BWC at OHIOBWC and follow the prompts, or use the MCO on BWC's Web site at ohiobwc.com. If you are unable to determine your MCO, mail or fax this form to the BWC customer service office closest to your home. For information on your local customer service office, please visit ohiobwc.com, or call OHIOBWC. Injured workers employed by a self-insuring employer Complete this form and give to your employer. Your employer should be able to tell you if he or she is a self-insuring employer. If your employer is self-insuring and you file this information with BWC, processing delays may occur. For assistance in completing this form, call your BWC customer service office Monday through Friday, 8 a.m. 5 p.m. Cambridge Southgate Road Cambridge, OH Phone: Fax: Canton 400 Third St., SE Canton, OH Phone: Toll free: Fax: Cleveland 615 Superior Ave. W. Cleveland, OH Phone: Toll free: Fax: Columbus 30 W. Spring St. Columbus, OH Phone: Fax: Dayton 3401 Park Center Drive Dayton, OH Phone: Fax: Garfield Heights 4800 E. 131 St., Suite A Garfield Heights, OH Phone: Toll free: Fax: Governor s Hill 8650 Governor s Hill Drive Cincinnati, OH Phone: Fax: Hamilton 1 Renaissance Center 345 High St. Hamilton, OH Phone: Fax: Lima 2025 E. Fourth St. Lima, OH Phone: Toll free: Fax: Logan P.O. Box W. Hunter St. Logan, OH Phone: Toll free: Fax: Mansfield 240 Tappan Drive, N. Mansfield, OH Phone: Fax: Portsmouth 1005 Fourth St. Portsmouth, OH Phone: Fax: Toledo P.O. Box Government Center, Suite 1136 Toledo, OH Phone: Fax: Youngstown 242 Federal Plaza, W., Suite 200 Youngstown, OH Phone: Toll free: Fax:

8 Completion instructions (continued) Injured worker and injury/disease/death info. Last name, first name, middle initial Social Security number Marital status Date of birth Single Home mailing address Sex Married Number of dependents 1 Male Female Divorced City State 9-digit ZIP code Country if different from USA Separated Department name 2 Widowed Wage rate Hour Month Week What days of the week do you usually work? Regular work hours $ Per: 3 Year Other 4 Sun Mon Tues Wed Thur Fri Sat From To Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Occupation or job title 6 Bureau of Workers' Compensation? YES NO If yes, please explain. 5 Employer name 7 Mailing address (number and street, city or town, state, ZIP code and county) Location, if different from mailing address Was place of accident or exposure on employer's premises? Yes No If no, give accident location, street address, city, state and ZIP code. Date of injury/disease Time of injury If fatal, give date of death Time employee began Date last worked Date returned to work 8 a.m. p.m. work a.m. p.m. 9 Date hired State where hired 11 Date employer notified State where 12 supervised 13 Description of accident (Describe the sequence of events that directly Type of injury/disease and part(s) of body affected injured the employee, or caused the disease or death) 14 (for example: sprain of lower left back, etc.) 16 SAMPLE Benefit application release of information I am applying for a claim under the Ohio Bureau of Workers Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits under the Ohio workers compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, and the Ohio Rehabilitation Services Commission (where relevant) to release medical, psychological, psychiatric, vocational or social information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer s BWC managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files. Injured worker signature Date address Telephone number ( ) Work number ( ) Home address: Enter the home address where the injured worker lives. Include the apartment number, if applicable. If the post office does not deliver mail to the home address, list the mailing address instead of the home address Date last worked: Enter the last day worked as a result of this injury, occupational disease or death. Date returned to work: Enter the date the injured worker returned to work after the injury or occupational disease. Injured worker and injury/disease/death info Department name: Enter the injured worker's department or area name where he/she normally reports for work. Wage rate: Enter the injured worker's rate of pay, and then select how often it is received. (If the pay rate being reported is not hourly, report the gross amount.) If eight or more days of work will be missed, BWC needs wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc. What days of the week do you usually work? What are your regular work hours: Enter the days and hours the injured worker normally works. If the days worked vary from week to week, list the number of hours worked in an average week. Wages: If you received wages during disability, please explain. Occupation or job title: Enter the injured worker's type of occupation or actual job title at the time of injury, occupational disease or death. Employer name: Enter the name of the injured worker's employer at the time of the injury, occupational disease or death. Date of injury/disease: Enter the date injured worker was injured. OR If the injured worker contracted an occupational disease, determine which of the following happened most recently: The occupational disease was diagnosed by a medical provider; The first medical treatment; The injured worker first quit work, due to the occupational disease. Enter this as the date of occupational disease State where hired: Enter the state where the injured worker was hired by the employer listed on this application. Date employer notified: Enter the date the employer was notified of the injury, occupational disease or death. State where supervised: Enter the state where the injured worker was supervised by the employer listed on this application. Description of accident: Describe in detail the events that caused the injury, occupational disease or death. Attach additional sheets, if necessary. Type of injury/disease and part of body affected: Describe the nature of the injury, occupational disease or death. Indicate the part(s) of body injured, affected or that caused the death. Examples: Laceration of first toe, left foot; Sprain of lower right back; etc. Injured worker signature (injured workers only): Please read the Benefit application/medical release information before signing and dating this form.

9 Tear off this sheet and return the completed form to your employer s managed care organization (MCO) or to your local BWC customer service office. By signing this form, I: Elect to only receive compensation and/or benefits that are provided for in this claim under Ohio workers' compensation laws; Waive and release my right to receive compensation and benefits under the workers' compensation laws of another state for the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am filing this claim; Agree that I have not and will not file a claim in another state for the injury or occupational disease or death resulting from an injury or occupational disease for which I am filing this claim; Confirm that I have not received compensation and/or benefits under the workers compensation laws of another state for this claim, and that I will notify BWC immediately upon receiving any compensation or benefits from any source for this claim. Injured worker and injury/disease/death info. ( Treatment info. Employer info. Last name, first name, middle initial Social Security number Marital status Home mailing address City State 9-digit ZIP code Sex Male Female Country if different from USA First Report of an Injury, Occupational Disease or Death WARNING: Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation to which he or she is not entitled, is subject to felony criminal prosecution for fraud. (R.C ) Date of birth Single Married Number of dependents Divorced Separated Department name Widowed Regular work hours Wage rate Hour Month Week What days of the week do you usually work? $ Per: Year Other Sun Mon Tues Wed Thur Fri Sat From To Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau Occupation or job title of Workers' Compensation? Yes No If yes, please explain. Employer name Mailing address (number and street, city or town, state, ZIP code and county) Location, if different from mailing address Was the place of accident or exposure on employer's premises? Yes No (If no, give accident location, street address, city, state and ZIP code) Date of injury/disease Time of injury If fatal, give date of death Time employee Date last worked Date returned to work a.m. p.m. began work a.m. p.m. Date hired State where hired Date employer notified State where supervised Description of accident (Describe the sequence of events that directly injured the employee, or caused the disease or death.) Type of injury/disease and part(s) of body affected (For example: sprain of lower left back) Benefit application release of information I am applying for a claim under the Ohio Bureau of Workers Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits under the Ohio workers compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, and the Ohio Rehabilitation Services Commission (where relevant) to release medical, psychological, psychiatric, vocational or social information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer s BWC managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files. Injured worker signature Date address Telephone number Work number ( ) Health-care provider name Telephone number Fax number Initial treatment date ( ) ( ) Street address City State 9-digit ZIP code Diagnosis(es): Include ICD code(s) Will the incident cause the injured worker to miss eight or more days of work? Yes No Is the injury causally related to the industrial incident? Yes No E code 11-digit BWC provider number Date Health-care provider signature Employer policy number Telephone number ( ) Fax number ( ) Was employee treated in an emergency room? If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code Certification - The employer certifies that the facts in this application are correct and valid. Yes No address Check if Rejection - The employer rejects the validity of this claim for the reason(s) listed below: Employer is self-insuring Injured worker is owner/partner/member of firm Federal ID number Manual number Was employee hospitalized overnight as an inpatient? Yes No For self-insuring employers only Clarification - The employer clarifies and allows the claim for the condition(s) below: Medical only Lost time Employer signature and title BWC-1101 (Rev. 1/31/2011) FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22) Date OSHA case number This form meets OSHA 301 requirements

10 Completion instructions (continued) Treatment info. Health-care provider name Street address Diagnosis(es): Include ICD code(s) 1 SAMPLE Will the incident cause the injured worker to miss eight or more days of work? Yes No Is the injury causally related to the industrial incident? Yes No E code 11-digit BWC provider number Date 3 Health-care provider signature 5 Telephone number Fax number Initial treatment date ( ) ( ) City State 9-digit ZIP code 2 4 Treatment info. 1 Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial incident, that the injury could result from the method (manner) of the accident, as described by the injured worker. It must be clear that the diagnosis in all probability occurred as a result of the injury. Providing a valid E code will enable us to determine the claim more quickly and efficiently. Enter the physician's or health-care provider's 11-digit BWC-assigned provider number. 5 Signature of the health-care provider completing this form. Employer info. 1 Employer policy number Telephone number ( ) Check if Employer is self-insuring Injured worker is owner/partner/member of firm address Federal ID number Manual number 2 SAMPLE Was employee treated in an emergency room? Yes No Was employee hospitalized as an inpatient? Yes No If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code Certification - The employer certifies that the facts in this application are correct and valid. 3 4 Employer: signature and title Fax number ( ) Rejection - The employer rejects the validity of this claim for the reason(s) listed below: For self-insuring employers only 5 Date Clarification - The employer clarifies and allows the claim for the condition(s) below: OSHA case number 6 1 Enter the employer's BWC-assigned policy number, which is located on the BWC certificate of coverage. 5 Self-insuring employers that choose to clarify certification may use the space provided. Attach additional sheet, if necessary. Employer info Enter the four-digit code that indicates the injured worker's job classification, located on the semiannual payroll report. If you do not know the injured worker's manual number, call OHIOBWC and follow the prompts. If certification is selected and the claim is allowed, it will promptly be paid. Employers certifying a claim waive both the notice of receipt and notice of first order of compensation. If rejection is selected, use the space provided to list the reasons for rejection. Attach additional sheets, if necessary. 6 If this is an OSHA-reportable injury, include the case number assigned by the employer. This form meets OSHA 301 requirements and may be used in lieu of the OSHA 301 when reporting recordable injuries and illnesses to the federal government. Note: If your employee misses eight or more days of work, BWC will need wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc.

11 Quick Reference Example 300AP Summary of Work-Related Injuries and Illnesses Completing the Summary Fill in the year to which this Summary pertains. Number of cases Copy the totals from 300P columns G, H, I, and J. Number of days Copy the totals from Log columns K and L. Injury and illness types Copy the totals from Log columns M1, M2, M3, M4, M5, and M Establishment information Enter the name and address information for the physical location that pertains to this Summary. You are required to maintain a Log and Summary for each physical location you operate. Include the entity code from the worksheets. BWC risk number Enter your BWC risk (policy) number before submitting and posting the form Enter the total number of employees in the appropriate descriptions for the type of entity. NOTE: List any teachers or instructors at state agencies, special districts, counties, cities, villages or townships under this category. Do NOT list them under the category for educational institutions. Only universities, colleges, technical colleges, schools and school districts should use the educational institution category OAC (D) specifies that the Summary must be signed by the employer, or representative of the employer who supervises the preparation of the Log and Summary. That person must certify that the information "is true and complete. Don t forget to post the Summary for your employees and submit it to PERRP! PERRP recordkeeping instructions, page 14

12 Blank 300AP Summary of Work-Related Injuries and Illnesse

13 Quick Reference Example 300P Log of Work-Related Injuries and Illnesses 1 2 Filling out the Log Fill in the year to which this Log pertains. Establishment name Enter the name and address for the physical location that pertains to this Log. You are required to maintain a Log for each physical location you operate Identify the person Enter information about the injured employee. If this is a privacy case as explained in these instructions, enter "privacy case" in the name field. Describe the case Describe the exact location, nature of the injury (including body part) and the workplace exposure that caused the injury Classify the case Place an X in column G, H, I, or J to indicate the outcome of the case. Important, check only one column and indicate the most serious outcome for the case. If the outcome changes, you must update the Log If applicable, enter the number of days away from work (K) or the Days of restriction or transfer (L). If both columns are applicable to a case, put a number in each applicable column. Place only ONE check mark in columns G, H, I or J for each case. 8 Place only ONE check mark in columns M1 through M6 for each case. 7 8 Place an X to indicate the type of case (M1 to M6). You must categorize all cases as either: Injury, Skin disorder, Respiratory condition, Poisoning, Hearing loss, or other illness. Total the columns Total all entries in columns G, H, I, J, K, L and M1 to M6. Transfer totals to the Summary. If you do not have an entry for a column(s), enter a zero ("0") and transfer the "0" to the Summary. 9 9 Transfer the column totals to the Summary! PERRP recordkeeping instructions, page 13

14 Blank 300P Log of Work-Related Injuries and Illnesses

15 Quick Reference Example 301P Injury and Illness Incident Report Incident documentation Filling out the 301P (or an equivalent) is the first step in gathering information about an injury or illness event. The supervisor of the injured worker or the person responsible for maintaining the required documentation can complete this form. You must collect all of the information on this form for each recordable injury or illness incident. BWC s First Report of an Injury, Occupational Disease or Death (FROI) is an acceptable substitute. PERRP considers a form equivalent if it contains ALL of the same information as the 301P. 5 2 Employee information Enter all of the requested information for the injured worker including the employee s hire date and job title. 6 3 Health-care provider information Enter information about the physician or practicing licensed health-care professional (PLHCP) and facility that provided treatment to the injured worker. 3 4 Case number Transfer the case number to the 301P when you enter the case on the Log. The case number may be the same as the BWC claim number or you may create your own unique identifier to track the case. You must obtain and maintain this form (or an equivalent) for every entry on the Log. You must retain the incident report for five years. PERRP encourages you to complete an incident report for every injury and illness event that occurs in your establishment (including incidents that do not meet the recording criteria in these instructions). Completing a report for every event provides important information that can assist you in maintaining a safe and healthy work environment Date and time of injury Enter the date of injury. IMPORTANT: You must complete this form and enter the case on the Log within six days of the incident. Incident details Provide a brief explanation in fields 14, 15, 16 and 17. The information must be specific and sufficiently detailed to explain the nature of the injury/illness event. Date of death You only complete this field if the event results in an occupationally related fatality. IMPORTANT: You are required to report all occupationally related deaths to PERRP within eight hours of the incident. PERRP recordkeeping instructions, page 12

16 Blank 301P Injury and Illness Incident Report

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19 Triad Local School District 7920 Brush Lake Road, North Lewisburg, Ohio, Last Edit: Superintendent s Office Treasurer s Office 937/ Home of the Fighting Cardinals Fax Fax 937/ WORKERS COMPENSATION TEMPORARY TOTAL DISABILITY BENEFITS OR SICK LEAVE BENEFITS ELECTION OF OPTION Employee Name: Social Security No.: Date of Work Related: Accident Incident Illness Check accident, incident or illness To the Employee: Please submit this completed form to the payroll office. If you are absent from work due to a work-related injury/illness, you must choose to receive either Temporary Total Disability benefits (TTD benefits) from Workers Compensation or be paid sick and/or annual leave, according to the Workers Compensation Temporary Total Disability Benefits/Sick Leave policy. If you elect to receive TTD benefits, you may use sick leave until you receive your initial TTD benefit check; however, this leave will be restored when you reimburse your employer the net value of the paid sick leave used, according to the provisions of this policy. OPTION 1 I elect to receive Workers Compensation TTD benefits; however, I understand that I may use sick leave and/or annual leave only until I receive my initial TTD benefits check. I understand that while receiving TTD benefits, I will be in a leave of absence without pay status. During this leave of absence without pay, I understand that I will continue to accrue tenure credit for reduction in force calculation and for the calculation of annual increment pay. I will accrue annual leave. I will not accrue sick leave and I will not be paid for holidays during this leave of absence without pay. OPTION 2 I elect to receive sick leave and/or annual leave benefits instead of Workers Compensation TTD benefits for the period that I am absent from work due to a work-related injury. While I am receiving paid leave benefits, I understand that I will continue to accrue annual leave, sick leave, and be paid for holidays that occur during this period. I also understand that while I am receiving paid leave benefits, I will continue to accrue annual increment pay and years of service credit for increment calculation as well as tenure credit for reduction in force calculation. After I exhaust my sick leave and/or annual leave, I understand that I am eligible to receive TTD benefits during any remaining period of absence from work due to a compensable injury. If I receive TTD benefits, I understand that while receiving these benefits, I will be in a leave of absence without pay status. During this leave of absence without pay, I understand that I will continue to accrue tenure credit for reduction in force calculation and for the calculation of annual increment pay. I will accrue annual leave. I will not accrue sick leave and I will not be paid for holidays during this leave of absence without pay. Employee s Statement: I understand that I must choose either Workers Compensation TTD benefits or paid sick leave and/or annual leave, and that I am not legally entitled to both for the same period. I understand that if I elect to receive TTD benefits and choose to receive paid sick leave and/or annual leave until I receive my initial TTD benefits check, I must reimburse the net value of the paid leave to my employer, who will then restore that leave. If I fail to reimburse my employer the net value of the paid leave used, I understand such amount will be deducted from future wage payments. Employee s Signature: Date Submitted: TO BE COMPLETED BY THE EMPLOYER This document was received by Signature: Date Received: THE TERMS OF THE OPTIONS ARE BASED ON CURRENT RULES ( ) AND ARE SUBJECT TO CHANGE THROUGH THE LEGISLATIVE RULE-MAKING PROCESS. Triad Local Schools: Successful learning today... productive living tomorrow."

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21 Home of the Fighting Cardinals Triad Local School District 7920 Brush Lake Road, North Lewisburg, Ohio, Superintendent s Office Treasurer s Office 937/ Fax Fax 937/ Date: Re: BWC Claim # Dear Physician: Triad Local School District has a transitional work program designed to assist an employee who has a work related injury to return to modified duty for a period of time, not to exceed 90 days, prior to being released to full duty in his/her original position. This program provides a temporary work assignment(s) while the injured employee completes the recovery process in order to return to his/her original job. Please complete the MEDCO-14 form regarding work recommendations. This form is used by the transitional work program committee to design temporary work assignments to comply with your restrictions. Thank you in advance for your assistance. Respectfully, Connie S. Cohn Treasurer Triad Local Schools: Successful learning today... productive living tomorrow."

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23 Physician s Report of Work Ability Instructions Physician must complete this form when the injured worker is under work restrictions or is temporarily totally disabled. You must send or fax a copy of the completed form to the managed care organization (MCO) and a copy given to the injured worker at time of exam. You may use any other physician-generated document provided that the substitute document contains, at a minimum, the data elements on the MEDCO-14. If injured worker is employed by a self-insuring employer complete this form and mail or fax it to the self-insuring employer. List ICD-9 codes for the allowed conditions being treated that prevent return to work. To Toll-free phone number Toll-free fax number Fax Note: From Phone number Fax number Injured worker name Injured worker occupation Claim number Employer name SSN if claim number unknown Date of injury / / WORK ACTIVITY May return to work (RTW) with no restrictions on May RTW with restrictions due to work-related injury/ disease from to (complete work/non-work capabilities on the right). Work restrictions apply to work and non-work activity. If restrictions cannot be met at work, then injured worker is recommended to be off work. The restrictions are permanent temporary? If temporary, how long? Is totally disabled from work from to. Please explain in the space provided below why the injured worker is unable to work, due to work-related injury/disease. List ICD-9 codes for the allowed conditions being treated which prevent return to work. Estimated RTW date Work/Non-Work Capabilities % of Workday (8 hr) Repetitions per hr None at all 0% Occasional 1-33% 4-6 Frequent 34-66% 6-12 Lift/Carry Up to 10 lbs lbs lbs lbs... Bending... Twist/turn... Reach below knee... Push/pull... Squat/kneel... Stand/walk... Sit... No lifting above shoulders... Hand restrictions Left Right Must wear splint No lifting greater than lbs No repetitive activities No work with hot or cold substances Continuous % >12 Change positions every Work activity as splint/bandage permits Avoid driving Keep wound clean/dry Limit working to Hrs./Day Physician s further explanation of work abilities or why the injured worker is unable to perform any work: No use of Left Right Arm Hand Finger Other REHAB MMI Has the work-related injury(s) or occupational disease reached a treatment plateau at which no fundamental functional or physiological change can be expected despite continuing medical or rehabilitative intervention (maximum medical improvement): Yes No Note: Periodic medical treatment may still be requested and provided. IF YES, give date IF NO, please explain (attach additional sheet if necessary) p Check if vocational rehabilitation return to work services are indicated. Physician name and address (please print, type or stamp) Date of this exam Follow-up appointment Date / / / / Time I certify the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment, or both. Physician signature (mandatory) BWC-3914 (Rev. 12/21/2010) MEDCO-14 Date / /

24 Completing the MEDCO-14 Physician s Report of Work Ability Instructions The MEDCO-14 is a physician s report of work ability. This form provides the injured worker and employer with important physician information regarding the injured workers ability to work and specific instructions to aid in recovery. 1. The physician of record or treating physician must complete this form every time the injured worker is seen and is under any work restrictions, off work, or working with accommodations. This form is not required if the injured worker is permanently and totally disabled or is not under any work restrictions. 2. This is a two-part form. Give one copy to the injured worker at the time of the office visit. Fax a copy to the appropriate managed care organization (MCO). If requested, you may send a copy directly to the employer. Note: If the injured worker is employed by a self-insuring employer, complete this form and fax or mail directly to the self-insured employer. 3. The Request for Temporary Total Compensation (C-84) is most often used to report an injured worker is temporarily totally disabled from work due to the injury and is requesting compensation benefits. However, you may use the Physician s Report of Work Ability (MEDCO-14) to report disability status. The injured worker must still complete and sign the front section of the C84 Form to extend compensation. 4. You may use any other physician generated document, provided that the substitute document contains, at a minimum, the data elements that are on the MEDCO-14. Benefits of successful early return to work Early and successful return to work (RTW) benefits everyone. The costs of any disability go far beyond the measurable costs for medical care and compensation payments. Early return to work initiatives are dependent on communication and cooperation by physicians, employees, employers, MCOs, rehabilitation specialists and BWC. Many employers have early RTW programs and are willing to accommodate physicians restrictions for their employees. A successful RTW program asks the injured worker pace himself/herself and not work beyond his/her limits. BWC encourages physicians to consider releasing the injured worker to full or restricted duty as soon as the injured worker is able, including midweek. Returning the injured worker midweek or as soon as medically able helps the injured worker both physically and psychologically. Most injured workers return to work right away with minimal assistance. But, some injured workers require more medical care resulting in longer recovery and time away from work. Some injured workers may even require vocational services to return to productive employment. Together, the injured worker, physician, MCO, employer, and BWC will create a RTW program that is personally tailored for the injured worker s job as well as the injury. There are several options available if the employer cannot make accommodations for the injured worker s restrictions. The injured worker may continue to receive temporary total compensation or be eligible for other types of compensation. The physician should communicate with the MCO to determine if the employer can accommodate other types of return-to-work options including: Transitional work - Work that uses real job duties for a specified period of time (generally not exceeding two or three months) to help injured workers progress to their original job; Modified work - Work in which physical barriers that may keep the injured worker from performing essential job functions are adapted, altered or removed; Light duty - Work in which the job requirements are performed at reduced physical capabilities. Job tasks may be temporary or permanent; Alternative work - Work for injured workers who are permanently restricted from their original jobs, but have other abilities and can be employed. Talk to the MCO if you feel the injured worker would benefit from vocational rehabilitation services. The American Academy of Orthopedic Surgeons and the American Association of Orthopedic Surgeons believe that safe early return-to-work programs are in the best interest of patients. Studies have demonstrated that prolonged time away from work makes recovery and return to work progressively less likely. Return to work in light duty, part-time or modified duty programs is important in preventing the deconditioning and psychological behavior patterns that inhibit successful return to work and in improving quality of life for the injured worker.

25 Last Edit: FILL OUT THIS FORM ONLY IF YOU PARTICIPATED IN THE TRANSITION TO WORK PROGRAM. TRANSITIONAL WORK PROGRAM EMPLOYEE SATISFACTION SURVEY 1. Were there enough providers for care available? 2. Were the providers for care easy to contact? 3. Was the scheduling of treatment timely? 4. Were the modified duties productive and contributable to the overall mission of the district? 5. Did the modified duties meet or exceed expectations? Copies sent to: Supervisor Treasurer

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27 Last Edit: FILL OUT THIS FORM ONLY IF YOUR EMPLOYEE PARTICIPATED IN THE TRANSITION TO WORK PROGRAM. TRANSITIONAL WORK PROGRAM EMPLOYER SATISFACTION SURVEY 1. Was the return to work of the employee as quick as anticipated? 2. Were the modified duties productive and contributable to the overall mission of the district? 3. Did the modified duties meet or exceed expectations? 4. What changes would you make to improve the transitional work program? Copies sent to: Treasurer

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