University of California Irvine HealthSystems Policy and Procedure Manual WORK-INCURRED INJURIES AND/OR GENERAL ADMINISTRATIVE ILLNESSES Date Written: 08/77 Date Revised/Revised: 08/03
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I. PURPOSE
The purpose of this policy is to ensure Workers’ Compensation benefits and assistance is provided to workers who are injured at work or develop a job related illness as a result of their employment.
II. BACKGROUND
The University’s self-insured Workers’ Compensation Program was established in accordance with California law. This program provides benefits to employees who are injured as a result of work related activities.
III. POLICY
It is the policy of the UCI Medical Center to provide Workers’ Compensation
benefits in compliance with California law. All persons serving the Medical Center as employees or *registered volunteers qualify for coverage. Claims handling,
decisions, benefits provided, and coverage are implemented in accordance with
California law.
State-mandatedworkers’ compensation benefits include:
A. Medical, surgical and hospital treatment which is reasonably required to cure or relieve the effects of injury which arise out of and in the course of employment. B. Temporary disability compensation while the employee is unable to work
because of the injury or illness.
C. Permanent disability compensation if any permanent physical impairment has resulted from the injury or illness.
D. Rehabilitation services for an employee whose treating physician determines that the employee cannot return to his/her regular job duties as a result of a work-related injury or illness.
UC Supplemental Benefits
IV. PROCEDURE
This procedure contains guidance for UCI Medical Center employees and managers to ensure proper reporting and treatment of work related injuries. Questions regarding this procedure should be addressed to the Worker’s Compensation Unit, UCI Medical Center.
RESPONSIBLE PERSON(S)/DEPT PROCEDURE Accident/Injury Reporting (Employee)
A. An employee must report work related accidents, injuries or illnesses to his/her supervisor (or any available supervisor) immediately, no later than end of the shift when the incident occurs. If no supervisor is available to contact, page the house supervisor at 714-506-6000 to report the injury. Employees should not delay treatment for urgent or emergency conditions if reporting the injury will result in treatment delay. Notifying Workers’ Compensation Unit (House Supervisor) Injury/Illness Treatment (Supervisor) Serious Injuries: Special Requirements (Supervisor/House Supervisor/Safety Officer)
B. Report the injury to UCI Medical Center Workers’ Compensation immediately via phone (456-6597) or fax (456-6505). Failure to report in a timely manner may create delays in acceptance of the claim and benefits due the employee. Provide the following information:
• employee name • accident type • nature of injury
• date and time of incident
• supervisor name and phone number, and • where the employee has gone for treatment, if
treatment was needed.
C. If treatment is needed, the employee should report to Occupational Health Clinic M-F 8:00-5:00pm. Urgent Care, 5:00pm-12:00pm and Emergency Dept from 12:00 midnight to 8:00am.
D. Accidents resulting in Serious Workplace Injury*, Illness or Death require special procedures and reporting as below:
*Serious injury is defined by CAL-OSHA as
1. amputation
2. serious permanent disfigurement e.g. crushing or severe burn, or
3. hospitalization exceeding 24 hours for other than
observation
Serious Injuries (continued) Ensuring Treatment (Supervisor/House Supervisor) Internal Reporting Reporting to Cal- OSHA E. Treatment
The supervisor must ensure that the employee receives prompt medical attention. Send the employee to the Emergency Department for emergent care. Accompany the employee if medically indicated. If your location is not at the hospital call 911.
F. Reporting Serious Employee Injuries
After ensuring the employee receives treatment, immediately notify the House Supervisor of the serious injury by paging 506-6000. If the accident occurs on the hospital site, the house
supervisor will meet the employee and his/her supervisor in the Emergency Department.
The House Supervisor will page or radio call the UCI Medical Center Safety Officer and call the Worker’s Compensation Office at 456-6597or fax the information to 456-6505. Information provided will include:
• Employee name • Employee department
• Type and severity of accident, injury or illness • Date and time of accident
• Supervisor name and phone number
• Whether and when Cal OSHA was notified and if so by whom
The following represents the order of responsible persons for subsequently reporting serious injuries to Cal-OSHA:
1. Safety Officer
2. House Supervisor – if the Safety Officer is
unavailable or unresponsive by page or radio within one hour of the initial page
Reporting Location: Cal OSHA:
Anaheim
2100East Katella Avenue, Ste 140 Phone: (714)-939-0145
Fax: (714)-939-0815
Information to provide Cal OSHA when calling: 1. Time and date of accident
2. Employer name, address and phone number 3. Caller’s name, job title
4. Address of accident site 5. Employer contact at site
(for UCI Medical Center, the employer
Accident Investigation (Worker’s
Compensation/ Supervisor/Employee)
Officer Shereen Uyeda phone 714-456-6738
6. Name, address of injured employee 7. Nature of the injury
8. Injured employee’s current location 9. List and identity of any other law
enforcement agencies present site of accident 10. Description of accident and whether accident
scene or instrumentality has been altered. G. After receiving a report of employee injury, the UCI Medical
Center Workers’ Compensation unit (456-6597) will email the supervisor an accident investigation form identifying the injured worker and the date of injury. The supervisor should complete the form and return it via email to Workers Compensation after completing the following:
• Investigate the accident; discuss it with the employee (identify the mechanism of accident, witnesses, and whether the employee wants medical attention, if not already provided). • Identify and resolve safety issues eg:
faulty or broken equipment to be repaired OR taken out of service.
• Assess/revise employee work practices to prevent future injuries
• Communicate proper safety procedures/identify hazards with all staff.
Worker’s Compensation Forms
Completing Forms 5020 (Supervisor)
H. Supervisors
Complete two forms when an employee work injury occurs: 1. Form 5020
Employer’s Report of Occupational Injury/Illness Form, 5020 (Rev. 6). This form (Exhibit A) for employee injury/illness must be completed and forwarded within
24 hours of the incident (immediately for serious
injuries).
Form 5020 is available from the Workers’ Compensation office in Human Resources, phone 456-6597. It is also available as an E form on the UCI Medical center intranet. (Do not give the form to the injured employee to complete)
• Complete (legible printing is allowed) • Sign
Providing form DWC-1 (Supervisor or Worker’s Compensation) Worker’s Compensation Forms (cont) Providing Information (Supervisor) 2. DWC-1 Form
EMPLOYEE CLAIM FOR WORKERS’
COMPENSATION BENEFITS DWC-1 Form (available from Worker’s Compensation): Supervisors or
designated employer representatives must give this form (or mail) to an employee within 24 hours of knowledge of an actual or reported work related injury or illness. The source of the information does not have to be the employee. Contact Worker’s Compensation unit if uncertain whether to provide a claim form.
Completing the form.
Put ONLY the employee’s name in the employee section of the form. Do not fill out anything else in the employee section. Then complete the employer’s section (bottom) and sign
Make two copies of the top (clearest) sheet: retain one, fax the other to Worker’s Compensation at 456-6505.
Provide the employee with the claim form (DWC-1)
3. It is the employee’s option to sign and return the claim form thus filing a claim, not a requirement. If mailing the form, fax a legible top copy with completed information to Worker’s Compensation at 456-6506 prior to mailing.
Keep accurate documentation regarding the accident, including all corrective safetymeasures and the names of any witnesses.
I. Once the form 5020 Employer’s Report is filed, the supervisor may be contacted by UCI Medical Center Workers’ Compensation and/or Octagon Risk Services to provide information needed to accept the claim. The supervisor’s cooperation and information obtained in the initial accident investigation with the employee will be important in expediting and/or determining claim acceptance or denial by ORS.
Benefits while awaiting a claim decision
work by a physician, other interim University benefits may be available to the employee through the UCI Medical Center Benefits office at 456-6636. The employee should always contact Workers’ Compensation unit as well, at 456-6597, in this event.
Assisting the employee through the process
(Supervisor Worker’s Compensation )
K. Maintain contact with the employee if he/she is on leave of absence. Injured employees may feel abandoned and need to be reassured that they are still a part of the department. L. Provide Transitional Work Assignments when the physician
requires temporary work restrictions. Ensure that work is provided that adheres to medically indicated work-restrictions.
M. Maintain the medical confidentiality of your employee. Do not ask the employee questions regarding his/her medical treatment or condition; focus discussions on his/her ability to work, the work schedule, etc. The employee may have questions. Refer him or her to the Workers’ Compensation office for claim questions, and to his/her medical provider for
medical questions. Worker’s Compensation Medical Leave of Absence Employee
Return to Work After Medical Absence (Employee)
N. To initiate a Worker’s Compensation Leave of Absence, provide the Occupational Health clinic written
documentation from your treating physician (except when Occupational Health clinic is the treatment provider)
Provide updated documentation of medical need for the leave of absence Updates should:
• Be written
• Be provided from the medical provider
• Indicate beginning and end dates
• If dates are extended, the written documentation should be provided prior to the original end date
• If appropriate the physician should describe work restrictions that would allow the employee to return to temporary transitional work.
This information should be sent, delivered or faxed to: UCI Medical center Occupational Health Clinic 101 The City Drive Rte 33
Orange, California, 92868
Phone: 714-456-8300
Fax: 714-456-6540
Exceptions:
(Employee/Supervisor )
Occupational Health Clinic will provide supervisors with the employee’s work status and restrictions at the time of each visit. Workers’ Compensation will receive copies of the work status from Occupational Health Clinic.
Ensure that all employees on any type of medical leave provide the following to Occupational Health clinic prior to returning from leave:
1. written clearance to return to work from physician 2. any specific work restrictions (in writing)
In order to ensure the safe return to work of the employee, the employee may be requested to be cleared by an
Occupational Health or other University-selected physician based upon the type of injury incurred, the degree and type of work restrictions given and the employee’s job
requirements.
Time Reporting Department Time Keeper/Supervisor
O. It is the responsibility of each department to ensure that the injured employee’s time is recorded in accordance with applicable University policies and bargaining agreements. UCI Medical Center’s Workers’ Compensation office will assist with questions.
Author: Sharon Haywood, RN
UCIMC Workers’ Compensation
Approvals: Directors’ Council November 04,2003
Performance Improvement Committee November 12, 2003
Med Exec Committee November 17, 2003
