COMPANY NAMEDate of Issue:

COMPANY LOGO

Early Safe Return to Work (ERTW)

PURPOSE:

An Early Safe Return To Work (ESRTW) program is a proactive approach to assist workers return to safe, meaningful and productive employment when medically able. The purpose of these procedures is to restore workers who have had injury or illness, through progressive, reintegration, into their regular job wherever possible.

Modified work is defined as any job, task, function or combination thereof, that a worker who is unable to safely perform without risk or re-injury or exacerbation of disability or risk to others. This may include working fewer hours, taking more frequent rest breaks, obtaining assistance from a co-worker for more difficult tasks, job/responsibility sharing, physical changes to the work environment, assisting devices, assignment to another job or special project work.

RESPONSIBILITIES:

Employee Responsibilities:

  • Report all accidents or illnesses immediately to the Immediate Supervisor, the Plant Manager or the WSIB Claims Management Coordinator
  • Assist the Supervisor, Manager and the WSIB Claims Management Coordinator in completing the required accident investigation reports
  • Obtain medical attention and advise the doctor of modified work availability (see WSIB Claims package)
  • Report back to the Supervisor or Manager after consulting with the doctor and submit restriction forms filled out by the doctor
  • Participate in the modified work activity

Supervisor or Manager Responsibilities:

  • Maintain a regular contact (weekly) with the absent injured employee
  • Ensure that the employee is given the correct duties (no other tasks are being done) in accordance with their restrictions on the assessment form
  • Monitor the employee on a daily basis while on modified work
  • Complete modified work evaluations weekly
  • Report to the Plant Manager or the WSIB Claims Management Coordinator if the employee on modified work experiences difficulty with the given modified work

Physician Responsibilities:

  • Where possible, complete the restriction form provided by the employee
  • Clearly identify the functional impairment of the injured employee and the time frame for recovery
  • Support COMPANY’S NAMEmodified work activity
  • Monitor the physical condition of the employee and recommend modification

Plant Manager or WSIB Claims Management Coordinator:

  • Ensure the resources are in place to develop, implement and maintain the modified work activity, including identifying and meeting training needs
  • Determine if regular work can be modified
  • With the assistance of the Human Resources department or WSIB Consultant, identify jobs that are suitable for modified work
  • Identify part-time positions for those unable to manage or complete an entire shift
  • Identify special modified work jobs that can be created for a temporary period, to be used only for the modified work activity
  • Liaise with the Health and Safety Committee or Representative if required
  • Keep minutes of all meetings concerning modified work
  • Communicate the goals and objectives of the modified work activity to all employees

PROCEDURES:

Every injury is to be reported to the employee’s Supervisor or Plant Manager. Where needed medical care will be provided. The employer will provide transportation to the nearest health care facility and back to the job site or home as needed.

The following WSIB claims package will be given to employee:

-Letter to the Injured Employee (Annex A1)

-Letter to the Physician (Annex A2)

-WSIB Treatment Memorandum (Annex B1 & B2)

-WSIB Functional Abilities Form (Annex C1 to C4)

-WSIB Claims Control Form (Annex D1)

-WSIB Form 7 - Workers Report (see Accident/Incident Reporting Procedures, Annex A to D )

-Weekly Progress Report (Annex E1 & E2)

The Immediate Supervisor or Manager and the employee will complete the Form 7, either before or after medical treatment depending on the situation. The employee must sign the Form 7. If they refuse, WSIB must be informed.

If unable to sign the forms, the WSIB Workers Claim/ Consent for treatment form is to be signed later. This form must be forwarded to WSIB no later than 48 hours after an incident occurs.

For any lost time injury/illness the Supervisor or Manager will notify the WSIB Claims Management Coordinator as soon as possible, no later than on the first day of business following the incident.

The immediate Supervisor or Manager will ensure that the employee is given a blank restriction form to be completed by the attending physician. The employee will return with the completed restriction form.

When the Functional Abilities Form is received an appropriate ESRTW program will be implemented. The Immediate Supervisor or Manager, in consultation with the WSIB Claims Management Coordinator will review the physical limitations with the employee and recommend the modified work that is available. They will determine with the worker the goals and objectives, expected duration and progression of the individual’s ESRTW plan. The employee either accepts or rejects the modified work.

On acceptance of modified work, the WSIB Claims Management Coordinator and the Immediate Supervisor or Plant Manager will monitor the employee’s progress. The ESRTW Program will be used to ensure compliance with identified task restrictions.

In a case of an employee rejecting modified duties without medical documentation, the employee will be advised that the case will be forwarded to WSIB for resolution.

Once an employee returns to work the WSIB Employer’s Subsequent Statement is to be completed and forwarded to the WSIB.

Dispute Resolution:

In the case of a dispute, decisions will be made with the input of the WSIB Claims Management Coordinator, the Immediate Supervisor andthe Plant Manager relating to further job placement. The employee, employer, physician and WSIB will work together to solve all disputes. The Plant Manager, the WSIB Claims Management Coordinatorand the Health and Safety Committee or Representative will be kept informed.

If the employee or Medical provider does not cooperate or does not provide appropriate information, the WSIB Claims Management Coordinator is to contact the WSIB Claims Adjudicator and the WSIB Nurse Case Manager and request assistance as needed.

RECORDS:

This program ensures continuous documentation and reporting to WSIB and the employee of all activities related to the employee’s claim for WSIB Insurance benefits. The written plan will be signed and dated by the injured/ill worker and the Immediate Supervisor or Manager, copied and forwarded to the WSIB Claims Management Coordinator. A copy will be given to the worker and another retained in the individual’s personnel file.

REPORTING:

The completed WSIB Form 7 (Workers Report) must be forwarded to the WSIB when there is a visit to the physician or there’s a lost time injury (loss of subsequent day of work).

The WSIB Workers Claim/ Consent for treatment is to be signed and forwarded to WSIB no later than 48 hours after an incident occurs.

The WSIB Employer’s Subsequent Statement is to be completed and forwarded to the WSIB once the worker has returned to work.

This completed Functional Abilities Form will be forwarded to the claims adjudicator as soon as possible. The Functional Abilities Form will be sent to the Health Care Professional every time the employee visits them.

REFERENCE MATERIALS:

  • Ontario Occupational Health and Safety Act
  • Workplace Safety Insurance Act & its Regulation 1101

Review
Dates / Reviewed By: / Changes Required?
“Yes” or “No”
Revised Date / Revised BY: / Approved By:

ANNEX – A 1–

Letter to the Injured Employee

Date:

Dear:

We are committed to assisting in your early and safe return to work. In order to be successful, we need to communicate with each other on a regular basis during your recovery, and we will work together to develop a work accommodation plan if necessary.

In order to help us identify work that is suited for you, we need to know what functional limitations, if any, you have. Please take the attached Function Abilities Form to your doctor to complete and then return it back to me as soon as possible.

Please ensure that the consent to release information is signed before the form is given to your doctor. I look forward to your successful return to work.

Sincerely,

Supervisor/Manager

ANNEX – A 2–

Letter to the Physician

Date:

Re:

Dear Doctor:

COMPANY”S NAME, in cooperation with the Worker’s Safety and Insurance Board, has established a Return to Work Program. This program is intended to assist a safe and timely return to work for our employees.

We would appreciate that you complete the attached Functional Abilities Form indicating the employee’s readiness to return to work. Please have the employee return it to us as soon as possible. Please identify any limitations and the duration of these limitations for our employee. The work assignments will be designed to suit the employee’s current needs and will not expose the employee to any conditions which might aggravate the injury, or cause re-injury.

We are committed to working with you and our employee to help them return to work. Thank you for your treatment of our employee and support in ensuring our employee’s return to work is successful. If you have any questions, please contact me atTELEPHONE NUMBER.

Regards,

COMPANY PERSONNEL NAME

WSIB Claims Management Coordinator

ANNEX – B1–

ANNEX – B2–

COMPANY NAMEDate of Issue:

COMPANY LOGO

ANNEX – C1–

COMPANY NAMEDate of Issue:

COMPANY LOGO

ANNEX – D1–

WSIB CLAIMS CONTROL

EMPLOYEE NAME:
SUPERVISOR’S NAME:
DATE OF INJURY:
RETURN TO WORK DATE:
(MODIFIED)
RETURN TO WORK DATE: (REGULAR)
WSIB CLAIMS MANAGER: / NAME:
TELEPHONE #
WSIB NURSE CASE MANAGER: / NAME:
TELEPHONE #
HEALTH CARE PROVIDER: / NAME:
TELEPHONE:
DATE FORM 7 SUBMITTED:
DATE WORKER’S CLAIM CONSENT SIGNED (IF NECESSARY):
DATE FUNCTIONAL ABILITIES FORM COMPLETED:
DATE TREATMENT MEMORANDUM (IF NECESSARY):
WEEKLY PROGRESS REPORT:
DATE EMPLOYERS SUBSEQUENT REPORT:
OTHER:

ANNEX – E1–

RETURN TO WORKPROGRESS REPORT

EMPLOYEE:______DATE:______

DEPARTMENT:______SUPERVISOR:______

START DATE:______PROGRAM LENGTH:______

WEEK #1

HOURSLIMITATIONS DUTIES OBSERVATIONS

WEEK #2

OBSERVATIONS

WEEK #3

OBSERVATIONS

WEEK #4

OBSERVATIONS

WEEK #5

HOURSLIMITATIONS DUTIES OBSERVATIONS

ANNEX – E2–

WEEK #6

OBSERVATIONS

WEEK #7

OBSERVATIONS

WEEK #8

OBSERVATIONS

WEEK #9

___HOURSLIMITATIONS DUTIES OBSERVATIONS

WEEK #10

OBSERVATIONS

CONCLUSION / RECOMMENDATIONS:

______