2017-2018 Workers' Compensation Packet August 31, 2017 This packet contains forms that must be used when completing a Workers' Compensation claim. Please throw away the previous packet.
Richmond City Public Schools Employee s First Report of Injury (Instructions for Completing) 1. Fill something in every line 2. If something does not apply, write in: N/A for not applicable. 3. Note: This Employee s First Report of Injury form must be completed by the employee and signed by the supervisor/principal before being sent to the RPS Dept. of Risk Management. 4. This report must be completed within 48 hours of the accident s occurrence. 5. You should make a copy and fax this form to: (804-780-8279). A hard copy original/w signature must also be mailed to: RPS Dept. of Risk Management, 301 N. 9 th Street, Richmond, VA 23219. 6. Please print or write clearly 7. Please note: Be sure to list the name of the school/work location where the employee (you) sustained this injury/illness. 8. List body part injured and type of injury 9. Describe in detail what happened and how it happened, including any equipment or witnesses involved. 10. Use descriptive words such as struck by or struck against, fall to below, fall at ground level, caught in, caught on or caught between, and overexposed or overexerted, etc., when describing the details of the accident. 11. If you have ideas concerning recommendations to avoid further injury, please list those in the description of incident section. If there are any questions or comments about completing this form, call RPS, Dept. of Risk Management at 780-4120. REV 08/17
Richmond City Public Schools Employee s First Report of Injury (Instructions for Completing) 1. Fill something in every line. 2. If something does not apply, write in: N/A for not applicable. 3. Note: This Employee s First Report of Injury form must be completed by the employee and signed by the supervisor/principal before being sent to the RPS Dept. of Benefits & Risk Management. 4. This report must be completed within 48 hours of the accident s occurrence. 5. You should make a copy and fax this form to: (804-780-8279). A hard copy original/with signature must also be mailed to: RPS Dept. of Risk Management, 301 N. 9 th Street, Richmond, VA 23219. 6. Please print or write clearly. 7. Please note: Be sure to list the name of the school/work location where the employee (you) sustained this injury/illness. 8. List body part injured and type of injury. 9. Describe in detail what happened and how it happened, including any equipment or witnesses involved. 10. Use descriptive words such as struck by or struck against, fall to below, fall at ground level, caught in, caught on or caught between, and overexposed or overexerted, etc., when describing the details of the accident. 11. If you have ideas concerning recommendations to avoid further injury, please list those in the description of incident section. If there are any questions or comments about completing this form, call RPS, Dept of Benefits & Risk Management at 780-4120. Rev. 08/17
WC #1 WORKERS COMPENSATION EMPLOYEE S FIRST REPORT OF INJURY The Employee s report MUST be completed in its ENTIRETY to report a Workers Compensation claim. The employee MUST sign the medical authorization in Section B. (Please write clearly). SECTION A: INJURY REPORT (to be completed by employee.) Employee Name: (Last, First) Home Address: ZIP Home Phone: Social Security Number: Date Of Birth: Location/school of incident: Date of Injury: Time: am pm Department: Job Title: Incident Description: Nature of Injury/Illness(including body parts affected) Were Safeguards or Safety Equipment: Provided: Yes No Utilized: Yes No Name of Witness: Supervisor s Name: Supervisor s Phone: SECTION B: MEDICAL AUTHORIZATION (TO BE SIGNED BY EMPLOYEE) In accordance with VA state law, I hereby authorize any physician or nurse who attended me, or a hospital at which I have been confined, to furnish to my authorized representative of Sedgwick, CMS, Inc., PO Box 85631, Richmond, Virginia 23285-5631, any and all information which may be requested regarding my physical condition and treatment rendered thereof and if necessary, to allow them or any physician appointed to me to examine any X-ray picture(s) taken of me, or to review records regarding my physical condition or treatment. A photocopy of this authorization is to be given the same force and effect as the original. Employee Signature: Date: I hereby elect to use my sick or vacation leave for the first seven (7) days of my absence: Yes No. If No, it will be Leave Without Pay. If injury is deemed compensable and you are completely placed out of work by your treating physician, starting on the eighth day, you may supplement the difference in pay with sick or vacation leave. I elect: Yes No to supplement the difference in pay. ****All injuries that happen while at work are not necessarily compensable injuries**** Rev. 08/17 Complete and Fax all pages to Risk Management at 804-780-8279
WC #2 WORKERS COMPENSATION PANEL OF DOCTORS HOW DO I CHOOSE AMONG THE PRIMARY CARE PANEL DOCTORS? You may want to select one of the panel doctors who participates in your health insurance plan just in case the claim is not covered by Workers Compensation. *** All injuries that happen while at work are not necessarily compensable injuries.*** Richmond Public Schools uses a panel of physicians to treat workers compensation injuries. (THE EMERGENCY ROOM MAY BE USED IN EMERGENCY SITUATIONS.) Employees are REQUIRED to select a physician from the panel below for treatment for the injury. This selected panel physician will make any referrals needed. ONCE EMERGENCY CARE HAS BEEN COMPLETED, A PANEL PHYSICIAN MUST BE SELECTED FOR FOLLOW-UP CARE. I have selected as my panel physician. I understand that if I choose a physician that is not on the panel, my medical bills will not be paid under workers compensation and will be my sole responsibility. I decline medical treatment at this time submit as RECORD ONLY Employee signature DATE: Supervisor s Authorization to treat: (Signature) WHAT IF I NEED A SPECIALIST? Your panel physician will refer you to any specialist you may need PRIMARY CARE PANEL DOCTORS Joseph Andriano, MD 804-254-5467(O) Monday thru Friday The Retreat Hospital 804-254-9898 (F) 8:00AM 4:00 PM 2621 Grove Avenue 24 hours/accident Care Richmond, VA 23220 Joseph Andriano, MD 804-483-1708(O) Monday thru Friday CJW Medical Center 804-320-3593(F) 8:00AM 5:00PM 7153 Janke Road 24 hours/accident Care Richmond, VA 23225 Dr. Richard Conyers 804-358-0361(O) Monday Friday Concentra Medical Ctr 804-358-4286(F) 8:00AM 5:00PM 9900 West Broad St Suite C Richmond, VA 23060 Dr. Richard Conyers 804-275-7200(O) Monday Friday Concentra Medical Ctr 804-743-2525(F) 8:00AM 6:00PM 9211 Burge Avenue Richmond, VA 23060 Dale Slagel, MD 804-747-5627(O) Monday Friday Henrico Doctor s Hospital 804-747-5702(F) 8:00AM 4:00PM 7700 E. Parham Road 24 hours/accident Care Richmond VA 23294 WHAT IF I HAVE A QUESTION? Any question regarding Workers Compensation, call Risk Management at 804-780-4120 or 804-780-8235. Rev. 08/17
RICHMOND PUBLIC SCHOOLS WORKERS COMPENSATION INSTRUCTIONS What To Do Supervisor s Responsibilities 1. Whenever an on-the job illness or injury occurs, it must be reported, without delay, to the employee s immediate supervisor. The supervisor must verify the time, location, cause, and type of injury. This information must be sent to the Risk Management Department immediately following the illness or injury. Again, it is critical that the employee is given the listing containing the Panel of Physicians at the time of the incident. The importance of this cannot be overemphasized. Selecting a physician from the list of panel physicians is a personal decision and must be made by the employee. 2. The employee must complete and submit the following forms within two (2) working days of the date of injury. Employee s First Report of Injury (WC #1) Workers Compensation Preferred Panel of Physicians (WC #2) Supervisor s Investigation Report (WC #4) must be completed within two (2) working days of the date of injury. Failure to report in a timely manner could result in a fine imposed by the Workers Compensation Commission. Please have injured employee complete (WC #3) Authorization for Medical Treatment Form prior to going to doctor for treatment. EMPLOYEE MUST RETURN THIS FORM TO THEIR SUPERVISOR. Please forward form to Risk Management (780-8279) upon your receipt. 3. Accommodations for return to work must be approved by Risk Management and the employee s Supervisor. It is the Supervisor s responsibility to maintain regular contact with employees losing time from work and to be aware of the injured worker s return to work status. All forms must be completed and signed, even in cases where medical attention is not needed and time is not lost from work. If employee declines medical treatment, please have them check the box declining treatment. Rev. 08/17
This form must be completed within the first forty-eight hours of an accident. The supervisor has the sole responsibility to fill out the entire form. Upon completion, immediately forward the report to: RPS: Dept.of Risk Management, 301 N. 9th St., Richmond, VA 23219 Fax Number: 780-8279 Employee Name? Date / Time of Accident? Name of School/Operations Where Accident Occurred?(Exmpl: Fox Elem - Science Rm) Occupation/Title of Injured? Part of Body Injured? Dept. Employee Works In? Type of Injury? Did Employee Receive First Aid Treatment at the School? Did Employee Receive Medical Treatment Off Site? Did Employee Return to Work the Same Day? What Was Employee Doing At the Time of the Accident? Describe in Detail How the Accident Occurred? What Was the Level of Supervision at the Time of Accident? Direct Supervision Indirect Supervision Unsupervised Was Employee Working Alone or With Someone Else? Witness Statement(s), if Any? (Use Back of Page if Necessary) Was Defective Equipment or an Outside Contractor a Factor? Factors Contributing to Accident? Improper Instruction Lack of Training Horseplay Failure to Lock out Equipment Physical Impairment Unsafe Equipment Taking Risk Poor Performance of Task Failure to Use PPE In a Hurry Wrong Tool For the Job Housekeeping OTHER Was the Lighting Ok? Yes No Slips & Fall Hazards? Yes No Was Employee's Attitude & Alertness Ok? Yes No Corrective Action? Discussed Acc. W/ Employee Discussed Acc. W/ Staff Retrained Verified Equipment Was Safe / Available Implemented an Inspection Program Repaired Equipment / Condition Referred Employee to EAP Initiated New Procedure Refer to "Instructions For Completing Supervisor's Accident Investigation WC#4 Revised 08/17
WORKERS COMPENSATION Authorization for Medical Treatment (To be presented to Emergency Room or Physician by the Employee) WC #3 Employee s Name Department Date of Injury Medical Panel Provider Selected Please examine and give necessary treatment to this employee who states that he/she received an injury in the line of duty. Please check appropriate blocks below. If injury/illness is not work related, so state and obtain medical insurance information. If you release him/her for modified work only, specify activities to be avoided such as bending, lifting, climbing, extensive walking, operation of motor vehicle, etc. Signed Date (Immediate Supervisor) Report of Treating Physician* Diagnosis Is this work related? Yes No This employee may return to: Regular duty on No duty (possible return date) Modified duty on Limitations Remarks or special instructions: Hospitalized No further treatment required Rev 08/17 Next appointment (date and time) Signed, M.D. Date *This form does not take the place of the Workers Compensation Commission s Physicians Report. ***No Medical Bills will be paid until this completed form is on file*** Fax completed forms to Risk Management at 804-780-8279 804-819-4400 (O) 301 N. 9 th St., 13 th Floor, Richmond, VA 23219