Jefferson County, Alabama Application for Injury with Pay Leave (Iwp)

JEFFERSONCOUNTY,ALABAMAAPPLICATIONFORINJURYWITHPAYLEAVE(IWP)

FORINJURYRECEIVED INTHE LINEOFDUTY

EmployeeApplication

FROM: ______

Employee

TO:

DepartmentHeadDate

I.ApplicantInformation

IncompliancewithJeffersonCountyPersonnelBoardRule13.12(revised4/05),Iherebyapplyforleavewithpayfor ______days,from ______,20__,

To ______,20__duetoinjuriesreceivedinthelineofdutyasfollows:

(Givedetailsbelow astohowaccidentoccurredandtheextentofinjury,andattachcertificateofattendingphysician.)

DateofInjury:______, 20__Time: MPlace:

Descriptionoftheon-the-jobinjury, includebodypart injured:_

Employeewassentto_Name(s)andAddress(es)ofpersonswitnessingaccident:

IherebywaiveanyclaimagainstTheGeneralRetirementSystemsforEmployeesofJeffersonCounty,ofwhichIamamember,andtowhichtheCountycontributes,fordisabilitypensionbenefitsfortheperiodduringwhichIWPisallowedunderthisapplication. I furthercertifythattheforegoinginformationistrueandaccurateineveryrespect. IunderstandandacknowledgethatImaybesubjecttodisciplinaryactionpursuanttoJeffersonCounty PersonnelBoardRulesforgivingafalse,incompleteormisleadingstatementinregardstothisIWPapplication.

WorkCenter/DepartmentNumberSignature ofApplicant

II.ReviewbyLineSupervisor

Aninvestigationintothecircumstancesoftheinjuryreported bytheemployeeasreferencedabovehasbeen completed.Thefollowingfindingsaresubmittedherewith:

YesNo

l.Didtheinjurydescribedaboveoccurwhilethepersonwasonthejob?

2.Wastheemployeecarryingoutassigned dutiesatthetimetheinjurydescribedaboveoccurred?(Ifno,explain:

3.Wastheinjurydescribedabovetheresultoftheemployee'snegligenceorfaultortheresult ofintoxication,druguse,illegalorimmoralconduct?

(ifyes,explain:_

4.Didtheinjurydescribedaboveresultfromtheviolationofaworkorsafetyruleofthedepartment? (ifyes,explain:

ImmediateSupervisorReviewingSupervisor

DateReviewCompleted

Ill.ReviewbyRisk Management

Theabove referencedemployeewasfirstseenbytheOccupational HealthPhysicianon

·.Basedonallmedicalinformationavailable,thefollowingfindingsaresubmittedherewith:

l.Didtheinjurydescribedaboveoccurwhilethepersonwasonthejob?

.2.Didtheemployeeprovideaphysician'scertificate describingthenatureandextentoftheon-the-jobinjury?

YesNo

3.Doesthephysician'scertificategivetheperiodofdisabilityandareturntoworkdate?

4.Istheemployee'sIWPapplicationsupportedbythemedicalinformationprovided? (Ifno,oralesserperiodwarranted,explain: _

DateRisk Management

IMMEDIATELYFORWARD TODEPARTMENTHEADWHENCOMPLETED!

IV.ReviewbyDepartmentHead

InaccordancewithPersonnelBoardRule13.12,Ihavereviewedtheaboveinformationrelatedtoyourallegedon-the-jobinjurywhichoccurredon

,20___,andwhichisdescribedinyourapplicationforInjurywithPayBenefits.ItismyrecommendationthattheJeffersonCountyCommission:

Approvedaysfrom_____,20__to

____ 20__.Nofurtheractionnecessary.

_____ Disapproveyourapplication.

_____Partiallyapprove _____ daysanddisapprove_____ days.

DepartmentHeadSignatureDate

NOTICE OFAPPEAL OFDEPARTMENT HEAD’S DECISIONTOAPPOINTING AUTHORITY

(Important!Ifyouappeal,accordingtoPersonnel BoardRule13.12(d),youmustfilewithinten(10)calendar daysfromthedateof Department Head'sDecision.)

Iwishtoappeal theabovedecisiontotheAppointingAuthority.

Signed:______Date:______

PrintedName:______Dept.______