Workers' Compensation

Wor

k

e

r

s

'

Compensation

Ac

c

ident R

e

porting Proc

e

dures

LISD FORMS AVAILABLE AT

THE SAFETY WEBSITE ARE IN

BOLD LETTERS

1.

Employee report

s

accident or near miss to campus

/

department Safety Officer

.

The

Safety

Officer i

s

u

s

ually an administrator such as an Asst. Principal.

2.

Safety Officer fills out

Supervisor's

Incident

report

(first injury report) using descriptors such as all body

parts (left & right) affected. NOTE: Distri

c

t Nur

ses

ar

e

n

o

l

o

ng

e

r r

e

quired to ass

e

ss or admini

s

t

e

r First

Aid to

employees as part of th

e

ir j

o

b d

esc

ripti

o

n.

3.

Consent for

Medical

Authorization

for medical records

and

reports

are signed by injured employee.

4.

Local Laredo

,

Texa

s

Workers

'

Compensation

Approved

Doctors List i

s

provided to employee a mor

e c

urr

e

nt

li

s

t is

a

vailab

le

on th

e

Texas W

o

rk

e

r

's

C

o

mp

e

n

s

ation w

eb s

it

e:

 www.tdi.texas.gov

5.

Safety Officer pro

v

ide

s

employee with a copy of the Supervisor's

Incident

report

(first injury report)

.

Employee seeking medical attention takes copy to an approved workers

'

compensation doct

o

r or to Minor/

ER

clinic that accepts workers

'

compensation insurance.

6.

Empl

oyee follows

up with Safety

Officer

and employee fills out

Statement

of Injured report

.

Special attention

is given to: Witness

Statements

, Corrective Actions and Safety Violations if any are noted. Safety violations may

involve

the use of work orders and

Personal Protective Equipment (PPE) as parts of Corrective Actions.

All of the

above mentioned reports should be faxed immediately to the LISD Workers’ Compensation office [795-3622]

preferably no later than the end of the work shift.

7.

Employees who miss work are

required

to access the district employee absence system.

8.

Employees

returning to

work (RTW).from

a work related injury

must be

cleared

by the LISD

Safety

Dept/Workers

Compensation

Program

,

pres

e

ntly Ms. Juanita Lop

e

z 273-1170, fax 795-3622. E-mail

:

jlop

e

z

@

lar

e

doisd

.

org.

9.

Employees returning to work with limitations and /or light duty will be accommodated at their assigned

campus

/

dept. u n l e s s HR and the Safety dept. deem otherwise. The employee will submit their RTW assignment

to their work site supervisor

/

administrator

.

HR will notify the employee

'

s former administrator

/safety officer of

any changes.

900 E. Lyon

•

Laredo, TX 78040

•

Ph 956-273-1170 WK

•

Fax

956-795-3622-E mail [email protected]

Laredo Independent School District Workers’ Compensation

EMPLOYEE RETURNING TO WORK PROCEDURE

1. Employee

receives

Information Packet

at time of

claim/report of

injury

2. Employee receives

Doctor’s Release and

Functional

Assessment

Or

DWC 73

3. Employee Reports

to Safety &

Occupational Health

Department with the

Workers’

Compensation Clerk

4. Employee is

issued “Request for

Authorization to

Return to Work”

from Workers’

Compensation Clerk

5. Employee

Reports to Human

Resources

Department with all

documents

6.

If approved to return

to work by Human

Resources, the

“Authorization” form

is signed &

authorized

7. Employee Reports

to his/her Job Site

with a copy of the

Approved

“Authorization” Form

8.

If Not approved to

return to work, Human

Resources will

Document reason for

Decline

9. Employee will be

informed of denial,

receive copy of

Documentation &

Instructed on

Necessary Action or

Process from

Employee and/or

District/ Human

Resources

10.

Copy of Completed

“Request for

Authorization to

Return to Work”

Form must be sent to

Workers’

Compensation Clerk

from Human

Resources

. Office tjseOitly Clana#:

TEXAS SCHOOLS COOPERATIVE

Medical Billing: J I Companies Fax: (512)346-9321

10535 Boyer Boulevard Suite 100 Toll Free Number: 800-580-5477

, Austin, TX 78758

WORKERS' COMPENSATION MEDICAL AUTHORIZATION FORM

TO WHOM IT MAY CONCERN:

I hereby authorize you to furnish to or its representative,

any and all information you may have concerning with respect

to any illness or injury, medical history, consultation, prescriptions or treatment, including z-ray plates,

and copies of all hospital or medical records. This applies to medical records while on active or reserve

duty with any branch of the United States Military and Naturalization records included. A photostatic

copy of this authorization shall be considered as effective and valid as the original.

Signed:

Address:

Date:

STATEMENT OF INJURED

PHONE NUMBER SOCIAL SECURITY NO.

HEIGHT WEIGHT

DATE OF BIRTH

COLOR OF HAIR

ADDRESS

PLACE OF BIRTH MARRIED / SINGLE NO. OF DEPENDENTS

COLOR OF EYES ANY PREVIOUS HEALTH COND1TIONS1?

• U YES LJ NO DESCRIBE ALL PREVIOUS HEALTH CONDITIONS AND/OR PHYSICAL DISABILITIES, IF ANY. ANY PHYSICAL DISABILITIES?

D YES U NO

JOB TITLE HOURS PER DAY DAYS PER WEEK NAME OF YOUR SUPERVISOR

DESCRIBE YOUR JOB DATE OF HIRE

DATE OF ALLEGED PLACE OF ALLEGED ACCIDENT ACCIDENT

HOW DID THE ALLEGED ACCIDENT HAPPEN (BE SPECIFIC)?

AVERAGE WEEKLY WAGE

$ TIME

NAMES AND ADDRESSES OF WITNESSES, IF ANY

DESCRIBE YOUR INJURY IN DETAIL

;

DID YOU EVER INJURE THIS PART OF YOUR BODY BEFORE?

D YES D NO

IF SO, WHEN AND WHERE?

ATTENDING PHYSICIAN

PHONE NUMBER

WERE YOU HOSPITALIZED AS A RESULT OF THE ALLEGED INJURY?

D YES D NO

DATE OF FIRST VISIT

ADDRESS

NUMBER OF VISITS IF STILL RECEIVING TREATMENT, HOW OFI'KN DO YOU VISIT PHYSICIAN?

NAME OF HOSPITAL

ADDRESS

WERE YOU COMPELLED TO STOP WORK BECAUSE OF THE INJURY?

D YES D NO HAVE YOU RETURNED TO WORK?

D YES D NO

DATE OF RETURN

ADMISSION DATE DISCHARGE DATE

LAST DAY WORKED

AT WHAT WAGES? AT WHAT JOB?

I herebv request and authorize vou to furnish to or its representative, any

HOUR AM. P.M.

AT WHAT JOB TITLE?

and all

(Name of Company)

information vou mav have concerning with respect to any illness or injury,

(Enter Your Name)

medical history, consultation, prescriptions or treatment, including x-ray plates, and copies of all hospital or medical records. Armed Service

Medical rooorda and HaturaliEation records infOiiripri A pVintnstatic copy of this authorization shall be considered as effective and valid Sis the

original.

ptiotnstatic copy of this authorization!

Signed:

-;.. Office Use Only Claimfc :• . - • • . .

SUPERVISOR'S INCIDENT REPORT

Full Name of Employee Involved/Injured:

Date of Alleged Incident: / / Time of Alleged Incident: AM/PM

Date Reported to Supervisor: / / .

Lost Time: Yes No First Day Lost Time: / / .

Return to Work: Yes No Date of Return to Work: / /

Exact Location:

Department: Job Title:

Job Site: Date of Hire:

Supervisor: Supervisor's Phone Number:

Was this accident preventable? Yes No

How could the supervisor help prevent this accident?

Was Physician Contact Necessary? Yes No

If yes, Date of Notification: / / Time: AM/PM

Physician Name: Phone:

Incident Facts; (Describe as accurately as possible what happened (i.e., if an injury resulted, state part of

body injured and nature of injury).

Were there witnesses? Yes No

If yes, list below.

Name: Name:

Department: Department:

Job Title: Job Title: __

Final Disposition: Include Description of Action Taken.

v:v, ..-. V.OfBceUse.Qnly

Claim #r''-"--. j-"'.-" -V-

---^U^-WITNESS STATEMENT

Witness Name: Age Phone #_

Witness Complete Address:

Witness Employer Name, Address & Phone:

If I should move or change my address, I can be located through:

Who resides at: ___

Name of injured employee: .. __ .. _ Date of Accident: _ ^ 200

Time of Accident: _ Place where accident occurred: _ Room _ Hall ___ Cafeteria

Other Location:

Please explain fully what you know about this accident:

Did you actually see this accident happen? If not, how did you learn about it?

Describe Injury (part of body affected):

Did this employee ever talk to you about getting hurt on the job?

If so, how soon after the accident did this conversation take place?

Do you know of any other injury, accident or illness that this employee has had?

If so, explain:

Has this employee worked since the alleged date of accident? _

If so, did he appear able to work as hard as before the accident?

If not, explain:

How long have you known this employee? Are you related to this employee?

If so, what is your relationship? _______

Please give the name and addresses of any other persons who might know anything about this accident:

a. ———

b.

c. _______

d.

Witness Signature: Date:

(USE OTHER SIDE IF MORE SPACE IS NEEDED)

RETURN THIS FORM TO SUPERVISOR WITHIN 24 HOURS OF THE ACCIDENT. COPIES TO: CORPORATE OFFICE & ICON BENEFIT