Injury and Illness Reporting Procedures for Templeton Unified School District

I. INJURED EMPLOYEE

A. Reporting Work-Related Injuries and Illnesses

1. Report all injuries, no matter how minor, to your supervisorimmediately upon realization that the injury or illness is work related.

2. If the work-related injury or illness is first recognized on a weekend or holiday, it should be reported to your supervisor at the start of the next workday.

3. If the work-related injury occurs before or after normal business hours and the approved medical clinic is closed (and you require immediate medical attention) you should contact your supervisor and then proceed to the nearest emergency room for treatment.

4. Any incident which caused a work-related injury should be reported even if no medical treatment was rendered at the time. When an injury or illness is reported,regardless of the severity, the Employee’s Claim for Worker’s Compensation Benefits (DWC-1) will be presented to the injured employee. Injured Employee must sign the Acknowledgement of Receipt of the Worker’s Compensation Claim Form (DWC1) and Notice of Potential Eligibility.

5. Provide your supervisor with the details of the incident and the nature of the injury.

B. Medical Treatment

  1. First aid for minor injuries such as cuts, scratches, burns or splinters may be administered at the school site by an appropriately trained individual.
  2. Injuries which require medical care by a physician.
  3. A PHYSICIAN’S AUTHORIZATION TO RENDER MEDICAL CARE ANDPHYSICIAN’S RETURN TO WORK EVALUATION form shouldbe obtained from your site administrator prior to seeking medical care. Emergency medical attention should not be delayed. If a medical emergency exists, forms can be completed following emergency medical care.
  4. After medical care has been rendered by the physician, you must return all appropriate paperwork to your site administrator. If you choose to file a Worker’s Comp claim, you should complete the "employee" section of the form, (1-8)and return it to your site administrator as soon as possible to avoid delays in treatment. Site administrator will give a copy to the injured employee as a temporary receipt.

C. Selecting a Physician

  1. If you have previously completed the PERSONAL PHYSICIAN PRE-DESIGNATION form, you may receive treatment from the doctor listed on the form.
  2. If you have not previously completed the PERSONAL PHYSICIAN PRE-DESIGNATIONform, the site administratorwill direct you to the worker’s compensation physician clinic selected by the district. Urgent Care by Twin Cities Community Hospital 500 First Street Paso Robles, CA 93446 Phone: 805-226-4222

D. Return to Work

  1. Following medical care from a physician, you must return the PHYSICIANS’ AUTHORIZATION TO RENDER MEDICAL CARE AND PHYSICIAN’S RETURN TO WORK EVALUATION form to the workers’ compensation clerkbefore you are allowed to return to work. This must be done immediately following medical care or the start of the next workday.
  2. If you are unable to return the form personally to your site administrator because of the injury or transportation problems, you must still contact them by phone as soon as possible.

II. SITE SUPERVISOR/SITE ADMINISTRATOR of INJURED EMPLOYEE

A. Provide Medical Care - Determine the nature and severity of the injury and ensure prompt medical attention. Do not delay medical treatment.

  1. If the employee requests to seek medical attention or you feel they need to seek medical attention due to a work related injury:
  2. Immediately notify the District Safety Coordinator, Chris Bonin at 434-5855.
  3. Immediately notify the district workers' compensation clerk, Karen Marik-Saad at 434-5809. If unavailable, contact Cyndi Waltmire at 434-5804.
  4. Provide the injured employee with EMPLOYEE’S CLAIM FOR WORKER’S COMPENSATION BENEFITS (DWC-1). The Claim Form (DWC-1) must be provided to the injured worker within one working day of the employer receiving knowledge of the injury to avoid penalties from the State. PLEASE DO NOT ADVISE THE EMPLOYEE TO FILL OUT THIS FORM. IT IS AT THE DISCRETION OF THE EMPLOYEE WHETHER THEY RETURN THE FORM OR NOT. If the employee does decide to fill out the DWC-1 form, make sure the EMPLOYEE fills out the top section (1-8) and you fill out the bottom section (9-18). Do not fill out the top section for the employee per York Insurance Services Group, Inc. After filling out the bottom portion of the form, give a copy to the employee as a temporary receipt. If completed by employee, forward the form to Karen Marik-Saad, district worker’s compensation clerk.
  5. Have the injured employee sign ACKNOWLEDGEMENT OF RECEIPT OF WORKER’S COMPENSATION CLAIM FORM AND NOTICE OF POTENTIAL ELIGIBILITY. Forward signed form to Karen Marik-Saad, district worker’s compensation clerk
  6. Review with the injured employee his or her responsibility regarding use of an appropriate doctor. If the employee has previously completed the PERSONAL PHYSICIAN PRE-DESIGNATION form, he or she may see the doctor selected on the form. Otherwise, the employee must go to a physician provided by the district. Urgent Care by Twin Cities Community Hospital 500 First Street Paso Robles CA 93446 Phone 805-226-4222
  7. Give the injured employee the PHYSICIAN’S AUTHORIZATION TO RENDER MEDICAL CARE AND PHYSICIAN’S RETURN TO WORK EVALUATION form before going to the clinic when possible or have it faxed to the clinic. Accompany the injured or ill employee to the clinic whenever possible.
  8. If the injury will require immediate emergency room treatment, transportation should be arranged by the District. Employees with serious life threatening injuries requiring emergency room treatment should be transported onlyby ambulance. Employees with non-life threatening injuries may be transported by District employees.
  9. If medical treatment can be administered on site or is not necessary:
  10. Interview the injured employee to determine what happened and if there was potential for a serious injury.
  11. If the incident had potential for serious injury, it should be investigated and documented using the SIPE ACCIDENT INVESTIGATION REPORT. The completed report must immediately be sent to District Safety Coordinator, Chris Bonin, for investigation.
  12. If the incident did not have the potential for serious injury, document it on aSIPE ACCIDENT INVESTIGATION REPORT.The completed report must immediately be sent to District Safety Coordinator, Chris Bonin, for investigation.

B. Accident Investigation - All work-related injuries or illnesses should be thoroughly investigated IMMEDIATELY FOLLOWING THE INCIDENT.

  1. Contact the district safety coordinator, Chris Bonin, at 434-5855, and provide the preliminary information.
  2. Interview all individuals that were directly involved with or witnessed the incident.
  3. Have the injured person and any witnesses provide a detailed account of the incident in writing. Have them sign and date the form.
  4. Investigate the scene of the injury.
  5. Take photos of the scene or the apparent cause of the injury/incident if necessary or possible.
  6. Complete the SIPE ACCIDENT INVESTIGATION REPORT.
  7. Complete all sections with as much detail as possible. Sign and date the form.
  8. With assistance from the district safety coordinator, ensure that appropriate corrective action is taken to prevent recurrence of the incident.
  9. Send a copy of the completed report to the workers’ compensation clerk, Karen Marik-Saad.
  10. Forward the original form to the District Safety Coordinator, Chris Bonin, immediately for investigation.
  11. Discuss the accident with all site personnel during the next regularly scheduled safety meeting.

C. Return to work

  1. Following medical care from a physician, the district must receive the PHYSICIAN’S AUTHORIZATION TO RENDER MEDICAL CARE AND PHYSICIAN’S RETURN TO WORK EVALUATION form. This should be done as soon as possible or when the employee returns to work.
  2. Be aware that every effort will be made to return the injured employee to work upon authorization from the physician.
  3. Temporary modification of existing jobs may be necessary to accommodate an injured employee with physical limitations and restrictions.
  4. A modified job which meets the employee's limitations may be provided in another department within the district. Temporary modified work will be provided through a joint effort of the Human Resources, workers compensation clerk and the safety coordinator.

Templeton Unified School District Safety Coordinator

Chris Bonin

(805) 434-5855

Fax (805) 434-2705

Templeton Unified School District Workers’ Compensation Clerk

Karen Marik-Saad

(805) 434-5809

Fax 805-434-1473

E-mail:

Alternate Contact

Cyndi Waltmire

(805) 434-5804

E-mail:

III. WORKER’S COMPENSATION CLERK

A Notification of Injury

A.Upon notification of a work-related injury for which an employee is seeking medical attention, the clerk shallverify the district safety coordinator knows of the incident.

B.Remind the employee to bring all paperwork received from the physician back to the clerk as soon as possible after the appointment.

C.Upon return from the clinic, provide the employee with an EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS (DWC-l) form. This form must be given to the employee within 24 hours of the employee seeking medical attention from a physician. If no medical care was provided, but the employee requests a claim form (DWC-1), they should be given one within 24 hours of the request.

D.Collect all paperwork from the injured employee and provide copies if requested.

E.If the injured employee fails to return to work after the medical evaluation indicates they can return to work without restrictions, the employee and physician should be contacted for clarification. Document the conversations.

F.If the injured employee was transported by ambulance, notify the SIPE office immediately at (805) 464-4142.

B. Medical evaluation and return to work

  1. If the physician has returned the injured employee to work without restrictions, the employee should be instructed to report to his or her supervisor with a copy of the PHYSICIAN’S AUTHORIZATION TO RENDER MEDICAL CARE AND PHYSICIAN’S RETURN TO WORK EVALUATION form confirming that the employee may return to his or her normal job duties.
  2. If the medical evaluation indicates any physical limitations, the employee's supervisor/site administrator should be contacted immediately to determine if temporary, modified work is available.
  3. If temporary, modified work is not available in the employee’s department, contact other departments in the district to determine if modified work is available.
  4. If temporary, modified work is not available anywhere in the district, immediately notify the HR Coordinator and safety coordinator for assistance.

C. Workers’ Compensation Form 5020 - Complete the EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS. Information can be obtained from:

  1. The SIPE ACCIDENT INVESTIGATION REPORT;
  2. The DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS, Form 5021;
  3. The RETURN TO WORK EVALUATION;
  4. Interviewing the injured employee and;
  5. Contacting the physician

D. Work directly with York Risk Services Group

  1. Send completed EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS form 5020 and the employees claim for workers compensation benefits (DWC-1) form to York Risk Services within five days of the district's knowledge of the injury. The on line 5020 reporting is required. If necessary, fax the information.
  2. Ensure that benefits are paid within the appropriate time frame.
  3. Provide additional information to assist in claims investigation.
  4. Act as liaison between the employee, Templeton Unified School District, and York Risk Services Group.

IV.SAFETY COORDINATOR

A. Evaluate the Incident- Upon notification of a work-related injury from the site administrator, the district safety coordinator will begin investigation based on the following information:

  1. Severity of the injury
  2. Potential for serious injury
  3. Probability for recurrence
  4. Violation of federal, state, or local regulations
  5. Possible unsafe conditions
  6. Time lost from work

B. Accident Investigation - If a thorough investigation is justified, the safety coordinator will conduct an independent investigation and document the findings.

  1. The results of the investigation will be communicated to the appropriate personnel in the school district.
  2. If information is obtained through the investigation which could affect the safety of personnel in other school districts, the SIPE Risk Management Committee should be informed.
  3. If the injury is fatal or serious (amputation, hospitalization, etc.), ensure the following are notified by someone from Templeton Unified School District:
  4. SIPE Executive Director;
  5. Division of Occupational Safety and Health (DOSH); and
  6. York Insurance Services.
  7. Superintendent
  8. If the employee was transported by an ambulance or theincident had the potential to cause serious injury or death, notify the SIPE Executive Director immediately.

C. Assistance - Provide assistance with accident investigations to supervisors/administrators.

D. Evaluating Investigation Forms - Evaluate all ACCIDENT INVESTIGATION forms completed by district personnel:

  1. Ensure that all information is appropriately documented and the form is complete including the proper signatures.
  2. Ensure that corrective action is appropriate.
  3. Ensure that corrective action is completed within an appropriate time frame.
  4. Return all incomplete accident investigation forms for the additional information as required.
  5. Forward complete SIPE ACCIDENT INVESTIGATION REPORT to workers’ compensation clerk ASAP.

E. Work directly with the district workers compensation clerk.

  1. Ensure that all employees who are returned to modified work by a physician are accommodated. It may be necessary to accommodate an injured employee in another department within the district.
  1. Provide assistance with difficult claims.

F. Ensure all appropriate personnel are trained.

  1. Procedures for accidents and injuries.
  1. Completion of appropriate forms.
  1. Accident investigation.

G. Work directly with SIPE for assistance and information.

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