G. Workers Compensation Claim Form: The form used to report a work injury or illness to your employer.

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2 F. Claims Adjuster: The term for insurance companies and others that handle your workers' compensation claim. Most claims adjusters work for insurance companies or third party administrators handling claims for employers. Some claims adjusters work directly for large employers that handle their own claims. G. Workers Compensation Claim Form: The form used to report a work injury or illness to your employer. H. Division of Workers Compensation: (DWC); A division within the state Department of Industrial Relations (DIR). The DWC administers workers' compensation laws, resolves disputes over workers compensation benefits, and provides information and assistance to injured workers and others about the workers' compensation system. I. Future Medical: On-going right to medical treatment for a work-related injury. J. Light Duty: An employee who is released by a physician to perform limited duties because of a temporary disability may be assigned to light duty at the discretion of the District. Light duty may consist of duties other than those normally performed by the employee and that are within the employee s medical restrictions. An employee assigned to light duty will be paid the regular wage rate for the job classification to which he or she was assigned prior to being temporarily disabled. K. Maximum Medical Improvement (MMI): an employee s condition is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Once MMI is reached, a doctor can assess how much, if any, permanent disability resulted from the work injury. L. Medical Provider Network (MPN): is a group of medical care providers, of mixed specializations, utilized by an employer that is approved by California Division M. Modified Duty or Work: Similar to light duty, it is a work assignment with physical demands that are within medical restrictions. N. Occupational Health Nurse (OHN): the specialty practice providing for and delivering health and safety services to district employees. The practice focuses on promotion and restoration of health, prevention of illness and injury and protection from occupational hazards. Must be a licensed Registered Nurse in the state of California. O. Permanent and Stationary (P&S): a medical condition that has reached maximum medical improvement. Once rendered P&S, a doctor can assess how much, if any, permanent disability resulted from a work injury. If the disability is rated under the 2005 schedule, the term maximum medical improvement (MMI) used in place of P&S. P. Permanent Disability (PD): Any lasting disability that results in a reduced earning capacity after Maximum Medical Improvement (MMI) is reached. Q. Registered Nurse: a graduate trained nurse who has been licensed by a state authority after passing qualifying examinations for registration called also RN. R. Self-insured Employer: An employer that has been issued a certificate of consent to self-insure as provided by Labor Code Section 3700 (b). Control Number: ADM-SOP 632 Page 2 of 11 Effective Date: 9/2/14

3 S. Settlement: An agreement between an injured employee and the district about workers' compensation payments and future medical care. Settlements must be reviewed by a workers' compensation judge to make sure they are adequate. T. Stipulation with Award: A settlement of a case where the parties agree on the terms of an award. U. Temporary Disability (TD): Payments awarded for wages lost due to an injury that precludes the injured employee from working. These payments are two-thirds of gross (pre-tax) wages at the time of injury, with minimum and maximum rates set by law. V. Third Party Administrator: An agent under contract to administer the workers compensation claims of a self-insured employer. W. Worker s Compensation Insurance: The social insurance system for industrial and work injuries regulated in certain specified occupations by the federal government. X. Workers Compensation Review Board: The Review Board, commissioners, deputy commissioners, presiding workers compensation judges and workers compensation judges. IV. Organizational Units Affected A. Risk Management Division 1. Manage the District s Workers Compensation Program (WCP). 2. Develop a written WCP program/procedure document. 3. Act as OCSD s liaison between the injured employee and TPA. The OHN will provide case management, with the TPA. 4. Assist injured employees with completing necessary forms (e.g. DWC1). 5. Conduct at least an annual review of the OCSD s WCP. 6. Recommend action to the General Manager, Director of Finance and Administrative Services, and Risk Manager regarding WC settlements issued by the TPA that are greater than $5, Training a. Provide training, as appropriate, to staff related to the District s Workers Compensation Program. b. Maintain employee training records for at least the duration of the individual s employment with the OCSD. c. Assist with providing any necessary training to ensure that the affected employee can safely perform the temporary light duty work assignment. 8. If employee was placed on modified duty (early return to work), develop in conjunction with the supervisor/manager, a written description of the accommodation(s)/temporary light duty work assignment for each case. Control Number: ADM-SOP 632 Page 3 of 11 Effective Date: 9/2/14

4 9. Develop, where appropriate, temporary light duty work assignment in other areas of the organization. 10. Inform and update the injured employee s supervisor of the employee s status. 11. Assist the injured employee s supervisor with approving vacation or time off if AME, PQME, or QME is scheduled prior to request. B. Purchasing Division 1. Act as the District liaison for all contract related issues with the TPA. C. Human Resources Division 1. Upon hire, notify employees of their right to designate a physician for treatment related to an injury/illness under Workers Compensation. 2. Initiate and engage interactive process with injured employee when necessary. 3. Assist with return to work when necessary. D. Employees 1. Are required to immediately report any work related injury/illness to their supervisor. 2. Complete the Workers Compensation Claim Form and submit it to the Risk Management Division no later than one business day following a reported work related incident. a. Employees are not required to return to work the next business day if the physician has taken them off work. 3. Inform treating physician of OCSD s work accommodations for early return to work, during the employee s initial visit. Request that the physician take this into account when determining the treatment process and to contact the Risk Management Division, OHN or Administrative Assistant, for assistance in explaining accommodations OCSD can make for work related injuries. a. If the physician places the employee on Temporary Light Duty: 1) Discuss the possibility of participating in Temporary Light Duty work with your supervisor/manager and the OHN. 2) Provide input to your supervisor/manager and the OHN, on a Temporary Light Duty work assignment that would cause the least impact on workflow and meet the medical restrictions set by the medical authority. 3) If your supervisor is not able to accommodate restrictions, work with OHN for possible Temporary Light Duty Work Assignment in another division or job duty. Control Number: ADM-SOP 632 Page 4 of 11 Effective Date: 9/2/14

5 4) Maintain at least weekly updates to the Risk Management Division, OHN and/or the Administrative Assistant, on medical status and treatments, etc. 5) Return to work when a Temporary Light Duty Work Assignment has been established and medical clearance has been granted. Report to the Risk Management Division; meet with the OHN to sign the Employee Acknowledgement Form. 4. Employees must request time off in advance of all non-emergency work related medical appointments, a. Requests must provide the information about the appointment including: schedule date and time and treatment type (i.e., doctor visit, physical therapy, etc.) 5. Employees shall submit medical certification following the WC appointment to the Risk Management Division which includes: a. The date of injury b. Physician s name, signature and telephone number c. Time in and time out for each appointment documented on the appropriate form. 6. Worker s Compensation Appointments may be scheduled by the employee, the Risk Management Division or the TPA. a. Employees shall report to work and work a minimum of five hours on the day of the appointment. b. A maximum of two and one half hours of SI leave including transportation time and treatment time shall be authorized per visit subject to approval. c. A maximum per week of 7.5 hours is allowed. d. Time charged to this benefit shall be coded on the time card (see Procedures for Work Related Injury - Time Cards section). e. Time for actual travel distances shall only be authorized. f. No overtime may be claimed for appointments outside of regular work hours. g. Additional time taken off in excess of 7.5 hours shall be coded as sick leave and subject to approval by Risk Management Division, provided that the minimum of five hours has been worked. h. Appointments outside of regular work hours are not compensable. i. Requests for time off, such as vacation, will need to be approved by Risk Management if an AME, PQME or QME appointment has been scheduled prior to the time off request. Risk Management will attempt to reschedule the appointment and will be approved if able to reschedule. E. Supervisors, Managers and Directors 1. Notify the Risk Management on the date of injury or illness. Control Number: ADM-SOP 632 Page 5 of 11 Effective Date: 9/2/14

6 2. Ensure the affected employee(s) files a WC claim form and submit it to the Risk Management Division, OHN and/or Risk Management s Administrative Assistant no later than the next business day following the reported incident. 3. Understand that employees are not required to return to work the next business day if the physician has placed them off work. 4. Contact the Risk Management Division, the OHN and/or Risk Management s Administrative Assistant to determine the status of a claim prior to approving leave. 5. Provide copies of time off requests and medical certifications from the physician to the Risk Management Division within one day of the medical appointment date. 6. Work with the Risk Management Division in developing a written accommodation(s)/temporary light duty work assignment for the injured/ill employee for the employees placed on Temporary Light Duty. 7. Meet with them employee and the OHN the first reporting day for a Temporary Light Duty Work assignment to ensure everyone has a complete understanding of the situation and the employee is comfortable with situation and sign the Employee Acknowledgement Form. 8. Maintain frequent communication with the employee on the progress of the assignment and determine if additional resources and/or training are required. 9. Notify the Risk Management Division, OHN and/or Administrative Assistant, prior to initiating any change or if any problems arise. 10. Will not approve time off requests, such as vacation, if an AME, PQME or QME appointment has been scheduled prior to the time off request. Final approval will be given by Risk Management, if the appointment is able to be rescheduled. V. Policy Statement A. OCSD shall implement a Workers Compensation Program (WCP), as a self-insured employer, under the requirements of the applicable sections within California Senate Bill 863 (2012). A Third-party Claims Administrator (TPA) shall manage this program as applicable and under the direction of OCSD. B. OCSD may authorize Sick-Industrial (SI) leave for medical treatment directly related to an industrial injury/illness when the TPA has accepted the claim for benefits and authorized the treatment appointments. 1. Sick industrial leave may be authorized when the TPA has delayed or denied a claim and the TPA has scheduled the injured/ill employee for a medical appointment. 2. Sick industrial leave time periods in general will be utilized for medical treatment procured using a pre-designated physician or a physician referral from OCSD. All other physician visits shall utilize regular sick time. Control Number: ADM-SOP 632 Page 6 of 11 Effective Date: 9/2/14

7 3. Sick industrial leave time periods will be determined on a case by case basis and must meet the procedures defined below: a. The leave is available to be used until the case is closed and/or awarded. b. Sick industrial leave shall not be authorized for any employee who has: 1) Received a Findings and Award from the Workers Compensation Review Board; 2) A claim which has been deemed closed by the TPA. VI. Procedures for Work Related Injury A. Employee reports injury immediately to supervisor and OHN. B. If emergency services are warranted call 2222, employee will be taken to the nearest occupational clinic or emergency room depending upon the severity of injury and time of day. C. Otherwise, employee may elect to see the OHN at the on-site clinic at OCSD and/or the employee will go to the appropriate clinic/doctor (see Industrial Medical Service Order) for medical evaluation and treatment. D. Supervisor and employee fill out the necessary paperwork as follows and send to Risk Management/OHN: 1. Safety Incident Report form: a. Complete the on-line form immediately following an accident, but no later than 72 hours. This form must be filled out even if the injured employee does not require medical attention. 2. Industrial Medical Service Order (IMSO): a. This is the form you give to the employee before you send him/her for medical attention. b. ProCare Work Injury Center 1) ProCare will be used for all non-emergency injuries. Irvine location hours are Mon-Fri 7 am to 6 pm and the Huntington Beach location is open Mon-Fri 8 am to 9 pm, Saturday 9 am to 6 pm and Sunday 10 am to 4 pm. 2) For injuries that occur outside of these hours an injured employee would go to the Irvine location only and the supervisor will need to call ProCare in Irvine to inform them that you are sending an employee over to the clinic. 3) This applies to both Plant 1 and Plant 2 employees. c. Pre-designated Physician (Other) 1) To use a personal physician who treats worker s compensation injuries or illnesses, the employee must designate the doctor before the injury occurs. Control Number: ADM-SOP 632 Page 7 of 11 Effective Date: 9/2/14

8 2) The Pre-designation agreement form must be signed by the doctor, and on record with the Risk Management Division. 3) The physician s name will be written in under other. d. Decline Treatment 1) If the injured employee declines medical treatment, he/she must also sign at the bottom of the IMSO, "declining treatment". 2) If employee does not go for treatment, send original to Risk Management Division. 3) The employee may ask for medical treatment for the injury at a later date. 3. Work status and paperwork from WC treatment a. If the injured employee receives medical care, and is given any type of paperwork regarding the WC injury, make a copy and give him/her the original. Send this copy to Risk Management s Administrative Assistant or OHN. 4. Employee's Claim for Workers' Compensation Benefits form (DWC-1): a. This form is given to the employee, regardless if medical treatment is provided. b. The top section of the form, questions 1-8 are filled out by the employee, and the bottom portion will be completed by Risk Management. c. Send the paperwork to the OHN or Administrative Assistant in the Risk Management Division. 5. Workers Compensation Leave Form: a. This form is given to the employee, regardless if medical treatment is provided. b. Have the employee fill it out and turn it in along with any paperwork from the physician. E. It is the supervisor s responsibility to see that the injured employee receives medical care. Another employee may drive him/her or they can drive themselves if able and their injury will not affect the operation of the vehicle. F. When the employee returns from receiving medical treatment, they should have with them a work status form or other paperwork from the doctor stating their injury and work restrictions, if any. This paperwork is given to their supervisor, who decides if the restriction(s) accommodations can be met, if there are any. The supervisor will work with the OHN and implement the Temporary Light Duty Acknowledgment Form. 1. Temporary Light Duty a. The Temporary Light Duty Acknowledgment Form is obtained from the Risk Management Division. If an accommodation is found, the employee will be assigned to a temporary position that maybe outside of the injured Control Number: ADM-SOP 632 Page 8 of 11 Effective Date: 9/2/14

9 employee s normal job classification but is within the medical abilities and limitations outlined by the treating physician. b. The employee, OHN and Supervisor of the position will sign the agreement which will be effective for 90 days. c. This is a temporary light duty work assignment that is subject to change and is not meant to exceed 90 working days per temporary job. d. If, at any time, the employee feels they are unable to perform the temporary job assignment or, if they should feel the physical requirements of the position exceed limitations placed by the physician, immediately notify your Temporary Supervisor and OCSD Nurse. G. If employee returns from the doctor with work restrictions which cannot be met by the division, the employee will be placed off work and receive TD payments. (However, availability of light duty outside the division will explored and duties other than their regular job classification that meets their restrictions may be offered. The employee s pay will not be adjusted while they are working in the restricted duties.) Employee cannot return to full duty work until they have a written release from the doctor. H. All of the paperwork is to be sent to Administrative Assistant or the OHN, Risk Management Division, within one day of the injury. This includes any follow-up treatment and/or any paperwork received from the doctor should be sent in as well. I. Time Cards 1. For all Worker s Compensation appointments such as physical therapy, follow up with the doctor, etc. all time cards so should use the: a. Pay Code Sick Industrial and Subledger , Sick Industrial (Wk Related/Inj) 2. If the employee is placed on TD (Temporary Disability), the employee should determine if they are going to use their vacation, sick pay, comp time or admin leave to augment their two-thirds of gross (pre-tax) wages. TD payments begin when your doctor says you can t do your usual work for more than three days or you get hospitalized overnight. a. Use Pay Code (Vacation, Sick, Comp or Admin Leave) and Subledger , Scheduled Leave All Types. 3. According to California Labor Code section 4652 Except as otherwise provided by Section , no temporary disability indemnity is recoverable for the disability suffered during the first three days after the employee leaves work as a result of the injury unless temporary disability continues for more than 14 day or the employee is hospitalized as an inpatient for treatment required by the injury, in either of which cases temporary disability indemnity shall be payable from the date of disability. For purposes of calculating the waiting period, the day of the injury shall be included unless the employee was paid full wages for that day. 4. Employees placed on TD and do not want to use or do not have accrued paid time off such as vacation, sick, comp time or admin leave should use a. Pay Code Unpaid time Off (AWL) and Subledger , Workers Comp. Control Number: ADM-SOP 632 Page 9 of 11 Effective Date: 9/2/14

10 VII. Recordkeeping All records created or generated in the course of this procedure shall be legible and stored in a way that they are readily retrievable in facilities or electronic document/content management systems that provide a suitable environment to prevent damage, deterioration, or loss. Records may be in the form of any type of media, such as hard copy or electronic media. The OCSD Records Retention Schedule is the official procedure governing the retention, retirement, and destruction of District records. Document owners should use these schedules to determine the item and series that best fit their records. Document owners are responsible for insuring that documents are properly marked, indexed, and filed for their projects or area of responsibility. VIII. IX. Exceptions/Conditions/Provisions References A. The Division of Workers' Compensation (DWC) monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits. B. Division of Workers' Compensation - Laws and regulations 1. California Code of Regulations, Title 8 2. DWC rulemaking - Proposed regulations 3. California Labor Code C. The State of California Labor & Workforce Development Agency (LWDA) is an executive branch Agency, and the Secretary is a member of the Governor s Cabinet. The Agency oversees seven major departments, boards, and panels that serve California businesses and workers. X. Revision History Version Date By Reason 0 10/27/04 Lisa Tomko 1 05/14/12 Gina Tetsch Update 2 08/28/14 Gina Tetsch Update XI. Attachments A. Claim Form Control Number: ADM-SOP 632 Page 10 of 11 Effective Date: 9/2/14

11 rs%20compensation%20claim%20form%20(dwc1).pdf B. IMSO Referral Form also Declination of Medical Care rial%20medical%20service%20referral%20form.pdf C. Incident Report Control Number: ADM-SOP 632 Page 11 of 11 Effective Date: 9/2/14