MakeYourReturn-to-Work

Process Fit Your Company

AtTexasMutualInsurance Company, wework hardtohelp employers maintain asafeworkplace,butweknowthatno business is immune toon-the-jobinjuries. When anemployee is injured on the job, your first responsibility istogethimorher promptmedical care. But don’t stop there. Texas Mutualencourages employers todotheirparttohelpinjured employees getwellandreturntowork.

What’s in it for employers?

  • Maintainproductionbykeeping experienced workersonthejob.
  • Avoid paying overtime, finding temporaryhelp or hiring someone new. Studiesshowthatthecostofreplacingexperienced workers can be twice their annual salary.
  • Controlworkers’ compensation claimcosts.

What’s in it for injuredworkers?

  • Steer clear of the stress and depression that often come withbeingunabletowork.
  • Retain their jobskills, company benefits and seniority.
  • Maintain their pre-injury income. Remember, workers'compensation benefits payonly a portion of the injured employee's salary.
  • Avoidthedisability mindset: "I'minjured,andIcannotwork."

Developingareturn-to-workprocessfora small business can be challenging. Often, themostdifficultaspectisputtingtheprocessinwriting.That’swhyTexasMutualInsurance Company created this guide. You caneasily adapt the examples on the following pagestofit your company’s needs.

Ifyouhavequestions,contact your Texas Mutual adjusterorsafety services consultant. Ifyouarepreparingdocuments with legalimplications,please consult your company’s legal counsel.

RemembertheBasics

A return-to-work process includes three key parts: assessing job tasks, identifying modifiedduties,and making abonafide offer of employment.

Assessing job tasks

Write down the separate activities ortasks involved ineach job atyour company. Includethephysical demands (suchaslifting,typing, standing)andthe environmental conditions(such as vibration, noise,heat)inyourdescriptions.

Identifyingmodifiedduties

Useyourtasklistto match the available worktotheinjuredemployee’sworkrestrictions,assanctionedbyhis or her treating doctor. Alwaystelltheemployee’sdoctor about the modified duties to make surethey meet the doctor’s restrictions.

Making a bonafideofferofemployment

If you can offer an injured employeemodifieddutiesthat meet hisorherdoctor’srestrictions,puttheofferinwriting.TellyourTexasMutualadjuster whether the injuredemployeeacceptsthe offer. If an injured employee refusesabonafideofferof employment, the employeemay lose his or her temporary incomebenefits.

PutItinWriting

Onthefollowingpages,we’veprovided sample documents toassistyouwithyourreturn-to-work process.Thedescriptions below explain how to use each one. If you havequestionsaboutthe documents orhowtousethem,callyourTexasMutualsafety servicesconsultantoradjuster.

Policystatement(Page5)

Write a policy statement that confirms yourcommitment to the return-to-work processand explains the return-to-work philosophy.Your policy statement should stress theimportance ofsafeoperations,immediate medicalcareafteran injury, and returning aninjured employee to work as soon as medically reasonable.

Employeeresponsibilities(Page7)

Writeproceduresthatexplain the steps an injuredemployee will take from the time ofinjury until afterthe employee returnstowork. Employees willunderstandthereturn-to-workprocessbetterandsupportitmorefullyifyouincludetheminthe developmentprocess.

Employeemeetingsheet(Page8)

Review the information on the policy statement, theproceduresandthe medical contactinformation with all of your employees. Be sure all employees sign the sheet to verifythattheyattendedthe meeting andunderstandthe process.

Physicaldemandstaskassessment(Page9)

Use this form to describe physical demands and environmental conditions for each job atyour company. Identify modified assignments to bring injured employees back to work.

Lettertodoctor(Page11)

Aletterofintroductionwill explain that your company iswillingtoworkwiththe doctor,the employee and the insurance company toprovide alternative productive work(modified duty) that will meet the employee’sworkrestrictions.Make arrangements witha doctor or clinic in your area for prompt medical care for your injuredemployees. If youhavea Texas Mutual® policy that includes theTexas Star Network®program, your injuredemployee must receive care froma networktreatingdoctor. Visit theHealthCareNetwork page at texasmutual.comfor a list of network providers.

Releaseformedicalinformation(Page12)

Have injured employees take a medicalinformationreleaseformwith them to the doctor.The doctor and the injured employeemaykeep a copy of the signed formfor theirrecords,andyour company cankeeptheoriginalsignedforminitsreturn-to-workfile.

DWC-73,WorkStatusReport(Page14)

Use this form to get the injuredemployee’smedical restrictionsas sanctioned by thetreatingdoctor.NOTE:TheTexas Department of Insurance, Division of Workers’Compensation(DWC) requires doctors toprovide this formto employers.

DWC-74, Description of InjuredEmployee’sEmployment(Page16)Use this form to describe the injuredemployee’s job duties tothe doctor. Thisinformation will help thedoctor determine whenthe injuredemployee canreturn to workat full or modified duty.

Checklistformaking a bonafideofferofemployment(Page18)Make sure your offer meets DWC requirements. Use this checklist to verify that youroffercomplies with DWC rules.

Bonafideofferofemploymentletter(Page19)

Send a bona fide offer of employment by certifiedmail to any injured employee who isabletoreturntoworkunderdoctor-sanctionedrestrictions.Ifthe injured employee doesnot speak or read English, contact your Texas Mutual adjuster.They will have the offer translated for you.

Modifieddutyworkagreement(Page20)

Havetheemployeeandthe employee’s supervisor (and return-to-work coordinator, ifapplicable) sign this form. The agreementstatesthat the employer will not ask theinjuredemployee to work outside of his or her medical restrictions.

Phonelog(Page23)

If an injured employee is physically unable toreturntowork,keep a phone log of allcontact with the employee,the treatingdoctorandany other involvedparty.Includethetimes anddatesofall contacts and attempted contacts. Maintain contactwiththeemployee regardless of how long they are off work.

ContactTexasMutualInsuranceCompany(Page24)

Ifyouhavequestionsabout creatingorupdatinga return-to-work process for yourbusiness, contact aTexasMutual safety services consultant or adjuster.

SamplePolicyStatementforthe

Return-to-WorkProcess

(Companyname) is committed to providing a safe and healthy workplacefor ouremployees. Preventing injuries and illnesses is our primary objective.

Ifan employee is injured, we will useour return-to-workprocess to provideassistance.We willget immediate, appropriate medical attentionfor employees whoare injured onthejob,andwewillattempttocreate opportunities forthemtoreturnto safe, productivework as soon as medicallyreasonable.

Our ultimategoalisto return injured employees to their original jobs. Ifan injuredemployee is unable to performall the tasks ofthe original job,we will make every effortto providealternativeproductivework that meets theinjuredemployee’scapabilities.

Thesupportandparticipationof management and all employees are essential for thesuccess of our return-to-work process.

President

DeclaraciónPolíticadel

ProcesodeRegresoalTrabajo

(Companyname) se compromete a proporcionarunlugardetrabajoseguroysaludablepara nuestrosempleados.Nuestroobjetivoprincipalesprevenirheridas yenfermedades.

Si unempleado se lastima,usaremosnuestroproceso de regreso al trabajo paraproporcionarayuda. Proporcionaremosatenciónmédicaapropiadainmediatamenteparalosempleados que se lastimenen el trabajoycrearemosoportunidadesparaqueregresenauntrabajoseguroyproductivolomásprontoposible.

Nuestrametaprincipalesregresaralosempleadoslastimados a sustrabajosoriginales. Siunempleadoesincapaz de realizartodas las tareas de sutrabajooriginal,haremostodoloposibleporproporcionaruntrabajoalternativoquevayadeacuerdoconlascapacidadesdel empleadolastimado.

Elapoyoyparticipacióndelagerenciaydetodoslosempleadosesesencialparaeléxitode nuestroproceso deregresoaltrabajo.

Presidente

SampleofEmployeeResponsibilities

RegardingWork-RelatedInjuries

Youareresponsibleforworkingsafely and following all safety rules.

If you are hurt on the job, you must report theinjury immediately to your supervisor andgo to the doctor that dayfor treatment, if necessary. We requiredrug testing aftereachwork-relatedinjury or illness.

Management is responsible for providing a safe work environment andforprovidingasmooth transition back to work for any employee who has experienced a work-relatedillness orinjury.

We will encourageanyone who is off work due to a work-relatedinjuryor illness toreturntoworkassoonas medically reasonable. Wewill provide modified worktasksasnecessary.

We will work together toset guidelinesformodified duty according to the doctor’srestrictions.

Itisessentialthatcontactbe maintained inorderto promote your return to work. We careabout your health, well-being and futurewiththe company.

Procedurestofollowafteranincident:

  • Report all incidents immediately, no matter how minor
  • Complete anaccidentreport
  • Provide correct informationimmediately so that the DWC-1 formmay becompleted and filed within 24 hours
  • Informthe physician that there is alternative productive workavailable
  • Report to work on the next scheduled shift afteryouhavebeenreleasedbythedoctor (either regular duties, modified duties, or reduced time)
  • Performonlythejobs described bythe doctor andmanager, according tothedoctor’s restrictions
  • Contact your manager weekly to discussyour restrictions and otherreturn-to-work opportunities
  • Verifythatwehaveyourcurrent phone number and address

Failure to followtheseprocedures will result in disciplinaryactionaccording to thepoliciesandproceduresinthe employee manual.

IhavereadandIunderstandallof the abovepolicies,andIacknowledgemyresponsibilities.

Employee Signature:Date:

Introductionto

TheReturn-to-WorkProcess

DATE:

TRAINER:

RETURN-TO-WORK PROCESS REVIEWED:

  • Policy statement andbenefitstothe employees
  • Proceduresto follow after an injury
  • Alternativeproductiveworkandbona fide offer of employment letterEMPLOYEES IN ATTENDANCE NAME SIGNATURE

EMPLOYEESNOTINATTENDANCEDATE OF TRAINING

PhysicalDemandsTaskAssessment

Task title:

Date:

Analyst:

Taskduration(hours/day):

With breaks: Yes / NoOvertime (avg. hours/week):

Task description

Postures / Hours at one time / Total hours per day
Stand
Sit
Walk
Drive
Lift/carry / None 0% / Occasional 0-33% / Frequent 34-66% / Constant 67-100% / Height oflift / Distance of carry
1-10 lbs
11-20 lbs
21-50 lbs
51-100 lbs
100 lbs
Actions, motions / None0% / Occasional0-33% / Frequent 34-66% / Constant 67-100% / Description
Pushing
Pulling
Climbing
Balancing
Bending
Twisting
Squatting
Crawling
Kneeling
Reaching
Handling
Fingering
Repetitive hand motion
Repetitive footmotion
Equipment used / None0% / Occasional 0-33% / Frequent34-66% / Constant 67-100% / Description
Tools
Machinery
Equipment
Environmentalconditions / None0% / Occasional 0-33% / Frequent34-66% / Constant 67-100% / Description
Vibration
Noise
Extreme heat
Extreme cold
Wet/humid
Moving parts
Chemicals
Electricity
Radiation
Other

Comments:

LetterfortheTreatingDoctor

(Date of letter)

(Doctor’s name)(Doctor’s address)

Dear (Doctor’sname):

(Company’sname) has implemented a return-to-work process. This process is designedtoreturnaninjured employee to the workplace as soon as medicallyreasonable. Theemployees at (Company’sname) are aware ofourdesiretoprovidealternative productiveworkintheeventofaninjury.

Ifoneofour employees isunabletoreturnto his/her original job,wewill make everyattempt to returnthisemployee to modifiedduties.We will also ensure thatthis positionmeets with ALL medical restrictions that you prescribe. If necessary, we are willing torearrange work schedules around diagnostic or treatmentappointments.

Our company has identified job duties that may be suitable for a “return-to-work”situation. Please call me at (company’stelephonenumber) if you have any questionsaboutourreturn-to-workprocessorthe alternative productive work available.

Wewouldalsoappreciateupdated information regardingthe employee’s statusaftereachappointment. Thank you in advance for your participation inoureffortstoreturninjuredemployees toasafeandproductiveworkplace.

Sincerely,

(Company’s representative)(Title)

(Companyname)

MedicalReleaseofInformation

Date

Claimant Name Claimant Street Address

Claimant City, State, zip

Re:Claim No:;Requestforthereleaseofnonpublicpersonal informationincluding personal health information.

Dear: (add name of claimant here)

(the “Employer”) isrequesting release of your nonpublic personalinformationfromthe treatingdoctor to aidinthe return-to-work process. This mayinclude medical andotherrelated information, as described in the attached authorization.The Employer isrequestingyourauthorizationtoobtainthisinformation.

Pleasereadtheattached authorization. It is valid for 24 months as written, but you mayauthorizethereleaseofyour nonpublicpersonal information foralesserperiodof timeontheauthorization.Onceyouhavesignedthis authorization,youmay laterrevokeitatany time bywritingtothe Employer at

(address), to the attention of (name).

Please sign and return the attachedauthorizationto my attentionat

(address). Signing and returning theauthorization will assist the Employer inthe return-to-work process.Thank you inadvanceforyourhelpin obtaining this information.

Sincerely,

(Nameof Requestor)

(Title of Requestor)

AUTHORIZATIONFORDISCLOSUREOFNONPUBLICPERSONALINFORMATION

Claimant Name: Claim No.:

By signing below, I,, (claimant)authorizemyhealthcareprovider,theiragents,employeesor representatives, to release to

(“the Employer”) for the return-to-work process, my medicalrecordsthatinclude: physical therapynotes,information or medical opinions includingdiagnosisandprognosis, information onworkstatus and activity restrictions,informationregarding impairment and disability, andinformationregardingmaximummedicalimprovement.

A copy or facsimiletransmission (fax) of this Authorizationisasvalid as the original.This Authorization is effective on thedate signed belowandwill remain in effect for 24months after signing, unless otherwise specified below.

I also understand that I have the legal rightto revoke thisAuthorization by writingto

(the “Employer”) at

(address),

Attn:. If the Employer oradisclosingentityhasalreadyactedinrelianceon my Authorization, my revocationwill notapply to that action or transaction.

Thepotentialexiststhata recipientofnonpublicpersonal informationmight re-discloseinformation used or disclosed pursuant to this Authorization, in which case medical andother privacy laws may no longer protect it.

Withlimitedexceptions, treatment,payment,enrollment inahealth plan, oreligibilityforbenefits may notbe conditioned on obtaining anAuthorization.

Signature of Claimant or person legallyauthorizedtoactfor Claimant

Please describe authority toact on behalf of claimantDate Signed

Time Authorization in Effect24months

ChecklistforMakinga

BonaFideOfferofEmployment

When the treating doctor releases aninjured employee toreturntoworkinanycapacity,youshould make abonafide(valid)offerof employment tothe employee. Makingabona fide offer of employment may affect the employee’s income benefits, so we mustconsiderthefollowing information (from DWC Rule 129.6) before we can determinewhetheranofferisbonafide.

Did you include a written copy of the Work Status Report (DWC-73) with theoffer?

Istheofferforajobata geographicallyaccessible location for the employee?

Isthejobconsistentwiththe doctor’s certification of the employee’s physicalabilities?

Did you communicate the offer to the employee in writing?

We have provided a sample letter on the following page to help you makea bona fideoffer.Beforeyoumakeanoffer,youmaywant to call us and ask for assistance. We canhelp if you havequestions or need additionalinformation. Follow this checklist when youwrite your own offer:

Include a copy of the Work Status Report (DWC-73) withtheoffer.

State the location at which the employee will beworking.

Indicate the scheduletheemployee will be working.

Statethe wages that the employee will be paid.

Give a description of the physical and timerequirements that the positionwillentail.

Includea statement indicatingthatyou, asthe employer, willonlyassigntasksconsistent with the employee’s physical abilities, knowledge and skills, and thatyou willprovidetraining, if necessary.

Remember: By making the offer in writing (and keeping a copy for your records), youwillbe able toprovethatyou made abonafide offer of employment in accordance withDWC’s requirements, should the need arise. Without a written offer on file, DWC couldrequirethe carrier (Texas Mutual InsuranceCo.) and/or the employer (you) to provide“clearandconvincingevidence”thatyou actuallymade the bona fide offer ofemploymentto the employee.

For moreinformation on bona fide offersof employment, call us at(800)859-5995orvisitourwebsiteat .

SampleBonaFideOfferofEmployment

CERTIFIED MAIL

RETURN RECEIPT REQUESTED

Date

Injured EmployeeAddress

Texas, Texas 70000 Dear:

(Company’sname) would like to offer you a temporary, modified-duty job assignment atour mainassembly plant at location.Thescheduleforthispositionisfromhours anddays of week, and the job payswages per hour. The job duties meet the work restrictionssanctioned by doctor’s name(see enclosed work status report).

Writea paragraph that describes the job duties,physicallimitations, maximumphysical requirements,and time requirements.

While you are working in this modified-duty job assignment, wewillonlyassigntasksthat are consistent with your physical abilities, knowledge, skills, and work restrictions assanctioned by (doctor’s name). We will providetraining, if necessary.

Please contactme byday and date at (phone number) if you are willingtoacceptthisoffer of a temporary, modified-duty job assignment.

Sincerely,

Name, TitleCompany

Enclosed: DWC-73, Work Status Report from(doctor’s name)

SampleModifiedDutyWorkAgreement

Employee’s name:Department: Employee’s title: Date: Myworkdutiesarechangedfrom (date) until (date).

I amassigned to modified work duties or limited duties.Mynewworkdutiesarelistedbelow.

Thedutiesabovehavebeen described to my doctor. My doctor has signed FormDWC-73 stating that I may do these activities underthefollowingmedicalrestrictions.

I agree to do the above work duties and follow my doctor’s medical restrictions. If Iignore my medical restrictions, I understand thatmy employer may takedisciplinaryaction.

If a supervisor or anyone else asks me todo work assignments or activities that don’tfollow mymedical restrictions,I must immediately reportthesituationto

(nameof return-to-work coordinator), whowill take action to correctthesituation.

IfI think my new work duties are causingdiscomfort or makingmymedicalconditionworse,Iwillreportthisimmediatelyto (name ofreturn-to-workcoordinator).

Employee signature:Date:

Supervisorsignature:

Date:

Return-to-work coordinator signature:Date:

MuestradeunAcuerdode

TrabajoAlternativo(SampleModifiedDutyWorkAgreement)

Nombre del empleado:

Departamento:

Puestodelempleado:Fecha: Misdeberesdetrabajohancambiadode (fecha)al (fecha).

Estoyasignadoalosdeberesdetrabajoalternativos o limitados.Misdeberes de trabajonuevosestánlistadosen la parte inferior.

______

Los deberesdescritosen la parte superior hansidoexplicados a mi doctor. Mi doctor ha
firmadouna Form DWC-73 estableciendo que yopuedo realizer estasactividadesbajo las
siguientesrestriccionesmèdicas.
______

Aceptolosdeberesdetrabajolistadosen lapartesuperioryseguir las restriccionesdeldoctor.Siignoromisrestriccionesmédicas, entiendo que la compañíaparalaquetrabajopuedetomaraccionesdisciplinarias.

Si un supervisor o cualquierotra persona me pidequehagatareasoactividadesquenocumplan con misrestriccionesmédicas,deboreportarlasituacióninmediatamentea

(nombre del coordinador del regresoaltrabajo),quiencorregirálasituación.

Si pienso que misnuevosdeberes de trabajoestáncausandoincomodidad o estánempeorandomicondiciónmédica,loreportaréinmediatamentea

(nombre del coordinador del regreso al trabajo).

Firma del empleado:Fecha: Firma del supervisor: Fecha: Firma del coordinadordelregreso al trabajo: Fecha:

After-InjuryTelephoneReport

Employee’s name:Home phone: Employee’s supervisor: Dateofinjury: Treating doctor: Doctor’sphone: Has the employer discussed workers’ compensation benefitswiththe employee?

YesNo

Has the employer discussed the return-to-work process withthe employee?YesNo

Log of Doctor’s Appointments

Date:Time: Comments

Contacted by:

Date: Comments

Time:

Contacted by:

Supervisor’sTelephoneLog

Date / Time / Comments

HowtoContactUs

Mainnumber

(800)859-5995

Claim reporting

Online

Fax(877)404-7999

Claiminformation

(800)859-5995

Safety services

844-WORKSAFE (967-5723)