WC Management Program

CSRMA: Workers’ Compensation Management Program

INITIAL INJURY PACKET

AGENCY:

WC COORDINATOR:

INSTRUCTIONS

An injury has occurred. Follow all instructions to complete this packet prior to medical treatment unless there is an emergency, in which case call 911, and then complete the packet as soon as possible after treatment.

Employee:

Read, complete and sign the Employee portion of the DWC Form 1 “Employee’s Claim for Workers’ Compensation Benefits.”

Complete and sign the top portion of the Incident/Accident Report.

Supervisor:

Complete the Employer portion of the DWC Form 1 “Employee’s Claim for Workers’ Compensation Benefits.”

Complete and sign the bottom portion of the Incident/Accident Report.

Contact the Workers’ Compensation Coordinator to determine if Employee has a pre-designated physician. If not, the Employee will receive medical treatment at the Agency’s clinic. Complete the top portion of the Treatment Authorization.

Telephone the clinic or the Employee’s pre-designated physician (whichever will be treating the Employee) to advise them that the Employee will be arriving for treatment.

If the Employee’s Usual & Customary job description is available, then make a copy, place it in the Treating Physician Envelope and check the box on the front of the envelope. If the job description is not available, contact the Workers’ Compensation Coordinator.

Complete standard Agency Safety procedures including, but not limited to, filing a Safety report.

Distribution of forms:

Place completed forms in envelopes as indicated. Distribute envelopes as follows:

Employee: Sign this envelope confirming receipt of Initial Injury Packet.

Employee: Keep Employee Envelope for records and reference.

Employee: Bring Treating Physician Envelope to clinic or pre-designated physician.

Supervisor: Place all remaining forms in this envelope and give it to the Workers’ Compensation Coordinator.

Employee: Sign here to acknowledge receipt of the Initial Injury Packet

EMPLOYEE’S SIGNATURE

CSRMA: Workers’ Compensation Management Program EE & SUP

INITIAL INJURY PACKET COMPLETE

DWC Form 1

EMPLOYEE’S CLAIM FOR

WORKERS’ COMPENSATION BENEFITS

-Insert form here-

Forms can be obtained from:

Gregory B. Bragg & Associates, Inc.

Claims and Risk Management

PO Box 619058

Roseville, CA 95661-9058

Tel: 916-783-0100

Fax: 916-783-0338

OR:

California State Department of Insurance / Division of Workers Compensation:

455 Golden Gate Ave.

2nd Floor

PO Box 429003

San Francisco, CA 94102

415-703-5011

http://www.dir.ca.gov/dwc/forms.html

A copy of the form is contained in the Instruction Manual (Forms Section) of this program.

CSRMA: Workers’ Compensation Management Program EE & SUP

INITIAL INJURY PACKET COMPLETE

INCIDENT/ACCIDENT REPORT

“Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation is guilty of a felony.” This notice has been approved by the Administrative Director of the Division of Workers’ Compensation (California Labor Code Section 5401.7)

EMPLOYEE COMPLETE TOP PORTION:

EMPLOYEE NAME:
Gender: M F / JOB TITLE: / FULL TIME
PART TIME
HOME ADDRESS: / AGENCY:
DEPARTMENT:
HOME TELEPHONE: / SUPERVISOR:
DATE OF BIRTH: / DATE OF HIRE:
INJURY DATE: / TIME: / LOCATION:
DATE REPORTED: / INJURY REPORTED TO (Name & Position):
NATURE OF INJURY (e.g., puncture, strain, cut, fracture, burn, etc.):
BODY PART INJURED (e.g., right wrist, left knee, head, lower back, etc.):
INJURY SOURCE (e.g., wet pavement, welder, keyboard, etc.):
HOW INJURY OCCURRED (struck by …, fell from …, exposed to …, etc.):
DESCRIBE ANY PREVIOUS CONDITIONS/INJURIES TO BODY PART CURRENTLY INJURED:
EMPLOYEE’S STATEMENT OF WHAT OCCURRED
(Include as much detail as possible such as activity being performed, objects carried, equipment used, hazardous conditions, etc.):
WHO WITNESSED THE INCIDENT?
Check this box if you previously completed a Declination of Medical Treatment Packet for this same incident.
EMPLOYEE’S SIGNATURE: / DATE:

SUPERVISOR COMPLETE BOTTOM PORTION:

EMPLOYEE’S REGULARY SCHEDULED HOURS:
total weekly hours; hours per day; days per week
DO YOU BELIEVE THIS INCIDENT SHOULD BE INVESTIGATED BY THE THIRD PARTY ADMINISTRATOR? YES NO
CHECK ANY THAT APPLY: / EMPLOYEE WAS NOT ON AGENCY BUSINESS ON DATE OF ALLEGED INCIDENT
INJURY/ILLNESS DOES NOT APPEAR TO BE WORK-RELATED
THERE IS A PRIOR INCIDENT OR OTHER CONTRIBUTING FACTOR
EMPLOYEE DID NOT REPORT INCIDENT UNTIL:
WERE ANY EMPLOYEES EXPOSED TO BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIAL (OPIM)? YES NO
IF YES, COMPLETE THE EXPOSURE INCIDENT PACKET
MEDICAL TREATMENT
EMPLOYEE DECLINED MEDICAL TREATMENT
EMPLOYEE TREATED AT CLINIC
EMPLOYEE TREATED BY PRE-DESIGNATED PHYSICIAN / EMPLOYEE TREATED IN EMERGENCY ROOM? YES NO
EMPLOYEE HOSPITALIZED OVERNIGHT? YES NO
IF EMPLOYEE DIED, DATE OF DEATH:
NAME OF PRE-DESIGNATED PHYSICIAN: / PHYSICIAN’S TELEPHONE:
PHYSICIAN’SADDRESS:
SUPERVISOR: / TITLE:
SIGNATURE: / DATE: / TELEPHONE:

If a work-connected fatality or hospitalization occurs, contact the local CalOSHA Area Office immediately at . The State of California requires every Employer to report such incidents immediately (within 8 hours) by telephone or in person to the nearest office of the division of Occupational Safety and Health. Reference: General Industry Safety Orders Section 342 Reporting Work-Connected Fatalities and Serious Injuries

Initial Distribution: Workers’ Compensation Coordinator

CSRMA: Workers’ Compensation Management Program SUP

INITIAL INJURY PACKET COMPLETE

TREATMENT AUTHORIZATION

Agency Clinic Pre-Designated Physician:

PHYSICIAN’S NAME

EMPLOYEE NAME: / DATE OF INJURY:
EMPLOYER: / EMPLOYER TELEPHONE:
TREATMENT
AUTHORIZED BY*: / SIGNATURE:
*Note: Bragg & Associates must approve any non-emergency treatment following this visit. Call (800) 922-5020 for approval.

Our Employee has been sent to your office for medical treatment of an injury that may be work-related.

Our Agency has a Return to Work policy and a Workers’ Compensation Management Program and will attempt to modify the current position or place the Employee into a Transitional Assignment during recovery. Review the Usual & Customary job description, if provided. You must use the enclosed Employee Status Report to outline the Employee’s current work capabilities.

Note that Labor Code Section 3762 (c) does allow for the release of the following medical information to the employer:

1) Medical information limited to the diagnosis of the mental or physical condition for which workers’ compensation is claimed and the treatment provided for this condition,

2) Medical information regarding the injury for which workers’ compensation is claimed that is necessary for the employer to have in order for the employer to modify the employee’s work duties.

Also note that according to the United States Department of Health & Human Services Office for Civil Rights, the HIPAA Privacy Rule permits covered entities to disclose protected health information to workers’ compensation insurers, State administrators, employers, and other persons or entities involved in workers’ compensation systems, without the individual’s authorization. (45 CFR §164.512)

Employee Status Report: Give original copy to Employee prior to leaving medical office

Fax a copy to the Workers’ Compensation Coordinator at

WCC FAX NUMBER

Payment: All billings should be sent to:

Gregory B. Bragg & Associates, Inc.

P.O. Box 619058

Roseville, CA 95661

Physician’s First Report: Send to Gregory B. Bragg & Associates, Inc. at the above address within 5 days of treatment according to Section 9785 of the Labor Code of the State of California.

Physical Therapy: Contact Gregory B. Bragg & Associates, Inc. at (800) 922-5020 for physical therapy authorization. Physical Therapy for Employees who are not Totally Temporarily Disabled should take place at a time and location that will cause minimal impact on the Employee’s workday.

This Agency will provide modified or transitional work for most work restrictions. Please advise of any work restrictions for the injured Employee in all Employee Status Reports. Any appointments, including physical therapy, should be scheduled to cause minimal impact on the Employee’s workday. If you have any questions, please contact the Workers’ Compensation Coordinator at the telephone number listed above.

Initial Distribution: Treating Physician Envelope

Physician: Retain for reference

CSRMA: Workers’ Compensation Management Program DR.

INITIAL INJURY PACKET COMPLETE

EMPLOYEE STATUS REPORT

CONFIDENTIAL INFORMATION

EMPLOYEE NAME: / DATE OF INJURY: / APPOINTMENT DATE: / TIME IN:
DATE OF BIRTH: / DEPARTMENT: / TIME OUT:
EMPLOYER:
(Name, Address, Telephone) / NEXT APPOINTMENT DATE: / INJURY TYPE:
Recordable
First Aid

“Yes, I have reviewed the Employee’s Usual & Customary job description prior to addressing work status.”

INJURY/TREATMENT / WORK STATUS
TYPE OF INJURY: / A. RELEASED TO USUAL & CUSTOMARY ON (Date):
PHYSICAL THERAPY:
sessions per week for weeks / B. RELEASED TO RESTRICTED DUTY ON (Date):
C. TOTAL TEMPORARY DISABILITY EFFECTIVE (Date):
SURGERY SCHEDULED?:
NO YES, DATE:
ANTICIPATED DATE OF
MAXIMUM MEDICAL IMPROVEMENT:

WORK ABILITIES

Maximum hours Employee can perform each activity per day
No
restriction / 6
hours / 4
hours / 2
hours / 1
hour / 0
hours / COMMENTS
Sitting
Standing/Walking
Squatting
Kneeling/Crawling
Climbing
Bending
Twisting
Pushing/Pulling / Weight limitations:

HAND/ARM USE:

Reaching
Fine Manipulation
Keyboard/Mouse Use
Simple Grasping
Power Grasping

LIFTING/ CARRYING:

0-10 lbs.
11-25 lbs.
26-50 lbs.
50+ lbs.
Can Employee work entire shift? / Yes No If no, how many hours?
Can Employee work overtime? / Yes No If yes, how many hours?
Does Employee need periodic rest breaks? / Yes No If yes, how often?
Can Employee operate/work around moving equipment? / Yes No
Can Employee operate a vehicle/forklift/heavy equipment? / Yes No
Can Employee operate vibrating equipment (jack hammer, etc.)? / Yes No
Can Employee wear a respirator? / Yes No
Can Employee enter/work in confined spaces? / Yes No
Can Employee work at heights? / Yes No
Is Employee on any medication that affects work ability? / Yes No If yes, explain:
PHYSICIAN INFORMATION
I declare under penalty of perjury that to the best of my information and belief I have not violated California Labor Code Section 139.3 and have not offered, delivered, received or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration for any referral for examination or evaluation by a physician.
NAME: / SIGNATURE: / DATE:
TELEPHONE: / FAX: / E-MAIL:
PHYSICIAN: Fax to Gregory B. Bragg & Associates, Inc. at (916) 783-0334 AND Workers’ Compensation Coordinator at:
AND give completed original to Employee to return to Supervisor.

Initial Distribution: Treating Physician Envelope

CSRMA: Workers’ Compensation Management Program EE KEEP FOR

INITIAL INJURY PACKET REFERENCE

CLINIC INFORMATION

IN THE EVENT OF AN EMERGENCY

DIAL 9-1-1

IN THE EVENT OF A NON-EMERGENCY WORK-RELATED INJURY OR ILLNESS:

SEE YOUR SUPERVISOR TO COMPLETE AN INITIAL INJURY PACKET

The Designated Healthcare Facility is:

NAME OF CLINIC:

ADDRESS:

TELEPHONE:

HOURS:

Insert Map Here

Initial Distribution: Employee Envelope

Employee: Retain for reference

CSRMA: Workers’ Compensation Management Program EE KEEP FOR

INITIAL INJURY PACKET REFERENCE

WORK STATUS GUIDE

After each medical appointment, report in person to your Supervisor and return the Employee Status Report. Your work status will be determined and you will be advised to take one of the following sets of actions:

A. If you are released to Usual & Customary position (full duty):

r Return to work and report for duty with your completed Employee Status Report from the Doctor.

r Return to Treating Physician for any indicated follow up appointments until you are released from care. Bring a completed Employee Status Report back to the Workers’ Compensation Coordinator in person after each appointment and receive a new Employee Status Report to take to the next appointment.

B. If you have any work restrictions:

r Your Supervisor and the Workers’ Compensation Coordinator will work with you to determine if an appropriate Transitional Assignment is available within your restrictions. If an appropriate position is available, review and sign the Transitional Assignment Agreement.

r If a Transitional Assignment is not available, your Workers’ Compensation Coordinator will keep in touch with you by telephone about every two weeks during your recovery.

r Continue treatment with the Treating Physician. Return an Employee Status Report to the Workers’ Compensation Coordinator in person after each appointment and receive a new Employee Status Report for your next appointment.

C. If you are Totally Temporarily Disabled:

r If you are unable to return to any assignment, your Workers’ Compensation Coordinator will keep in touch with you by telephone about every two weeks during your recovery.

r Continue treatment with the Treating Physician. Return an Employee Status Report to your Workers’ Compensation Coordinator in person after each appointment and receive a new Employee Status Report for your next appointment.

Initial Distribution: Employee Envelope

Employee: Retain for reference

CSRMA: Workers’ Compensation Management Program EE

INITIAL INJURY PACKET COMPLETE

MILEAGE REIMBURSEMENT FORM

DATE:

RE: EMPLOYEE:

ADDRESS:

EMPLOYER:

CLAIM # (if known):

DOI:

You are entitled to transportation reimbursement for medical visits at the currently allowed statutory rate. Please keep track of the dates of your appointments and miles traveled for each appointment. Request reimbursement using this form or the form provided by the claims administrator. Parking expenses and toll bridge costs will also be paid if receipts are submitted. You will not be reimbursed for mileage driven in a company vehicle. Photocopy the blank form so that you have additional copies for future use.