Ventura County Schools Self-Funding Authority
Workers’ Compensation
Guidelines
Version 1.1
August 2014
Prepared by YORK Risk Services Group, Inc.
Table of Contents
Introduction ...4
Self-funded program ...4
Contacts...5
Information and Assistance Office: ...6
What is Workers’ Compensation? ...7
No-fault, mandatory coverage ...7
What is not covered? ...7
Eligible employees, volunteers, and ROP students ...7
Workers’ compensation benefits...8
Medical Care ... 8
Temporary Disability Benefits ... 9
Permanent Disability Benefits ... 10
Vocational Rehabilitation Services ... 10
Supplemental Job Displacement Benefits ... 10
Death Benefits ... 10
Supplementing Temporary Disability Benefits ...11
Overview ...11
Industrial Accident Leave ...11
Accrued Sick Leave and Accrued Vacation Leave ...12
Extended Sick Leave...12
39-Month Rehire List ...13
Transitional Duty ...13
Pre-Designating a Doctor ...14
Employees who pre-designate ...14
Employees who do not pre-designate ...14
Claims Filing Responsibilities ...15
Employees ...15
Employers ...16
Oc-Med Program ...18
Injury Prevention Program ...18
Denied Claims ...20
Appendix B ...23 Appendix C ...27 Appendix D ...29 Appendix E ...31 Appendix F...33 Appendix G ...37 Appendix H ...42
Introduction
The Ventura County Schools Self-Funding Authority (VCSSFA) is a Joint Powers Authority (JPA) that provides its member agencies with Workers’ Compensations coverage and services through a self-insured Workers’ Compensation Program. VCSSFA utilizes an outside company, YORK Risk Services Group, Inc. to administer the benefits.These guidelines were prepared by YORK Risk Services Group, Inc. to help members understand the Workers’ Compensation Program that VCSSFA offers and the procedures to follow when an employee is injured or becomes ill as a result of work-related activities. All members are encouraged to read this publication and share it with administrative leaders and supervisors.
Self-funded program
The members of VCSSFA have elected to self-fund its workers’ compensation liability rather than purchase an insurance policy. This means that medical bills and all other benefits are paid directly from VCSSFA Funds. Medical treatment associated with work related injuries is provided through the JPA’s Medical Provider Network (MPN), WellComp.
There is no insurance company involved.
VCSSFA’s greatest concern is to see that every employee receives the best medical care and attention available in order to ensure rapid recovery and return to work. The State of California supervises both the amount of benefits available under workers’ compensation and the distribution on all payments.
Contacts
Any questions or inquiries related to the Member Agency’s workers’ compensation coverage through VCSSFA should be directed to the staff of the JPA. All employee questions and inquiries about workers’ compensation or specifically about a claim should be directed to the claims staff at YORK Risk Services Group, Inc. If an employee feels he/she needs additional information or clarification, the employee can also the State of California Division of Workers Compensation.
CONTACTS
Ventura County Schools Self-Funded Authority
Elizabeth Atilano, Executive Director5189A Verdugo Way Camarillo, CA 93012 805.383.1969
805.383.1971 fax
Claims Administrator
YORK Risk Services Group, Inc. P.O. Box 619079Roseville, CA 95661 805.288.4100 866.548.2637 fax
Jody Gray, President 714.620.1336
Devora Brainard, V.P. WellComp 951.231-6825 x 225
Nichole Martinez, Client Services 909.942.4875
[email protected] Winston McCathan, Manager 805.288.4062
[email protected] Brianna Santos, Claims Examiner 805.288.4084
Dorothy Davis , Senior Claims Examiner [email protected]
805.288.4071
Greg Bowles, Claims Examiner [email protected] 805.288.4256
Rose Ramirez, MO/Future Medical Examiner [email protected]
805.288.4063
Silvia Orozco, Claims Examiner [email protected] 805.288.4073
Suzanne Rios, Senior Claims Examiner [email protected]
805.288.4076
Information and Assistance Office:
Worker’s Compensation Appeals Board1901 N. Rice Rd Suite 200 Oxnard, CA 93030
Information and Assistance Officer Tina Urias
805.484.3528 800.736.7401
Direct Line: 805.485.3588 Fax: 805.485.6339
What is Workers’ Compensation?
No-fault, mandatory coverage
Workers’ Compensation is a state-mandated coverage in California for all eligible employees who are injured or become ill as a result of their employment. An employee could be injured in one incident while at work or through repeated exposures at work.
Workers’ Compensation is a no-fault system, meaning that injured employees need not prove the injury was someone else's fault in order to receive workers' compensation benefits for an on-the-job injury.
The workers' compensation system is based on a trade-off between employees and employers – employees should promptly receive the statutory workers' compensation benefits for on-the-job injuries, and in return, the workers' compensation benefits are the exclusive remedy for injured employees against their employer.
What is not covered?
Typically, workers’ compensation does not cover injuries that occur outside of work, or are due to personal illness, self-inflicted injuries, intoxication, or personal disputes.
Eligible employees, volunteers, and ROP students
The VCSSFA workers compensation program applies only to the member agencies’ employees and substitutes, volunteers, and students in a Member Agency-authorized Regional Occupational Program (ROP) provided that the following requirements are met:
Employees and Substitutes
• The injured or ill person must be a full-time or part-time employee – i.e., registered in the Member Agency’s payroll system. Contractors, consultants, vendors, and other third parties are generally covered by their own employers’ workers’ compensation program.
• The injury or illness must be sustained within the course and scope of the person’s employment.
Volunteers and ROP Students
• The VCSSFA workers compensation program also covers volunteers and students in a Member Agency-authorized Regional Occupational Program (ROP) who are not paid a salary.
• The injury or illness must be sustained within the course or scope of the volunteer or ROP duties.
For the purpose of workers' compensation coverage, a volunteer is defined as a person rendering services to the Member Agency where the Member Agency has control and direct supervisory responsibility over the manner and result of the services rendered; and the volunteer receives no remuneration for such services other than meals, transportation, lodging, or reimbursement for incidental expenses, if appropriate.
Workers’ compensation benefits
There are six basic types of workers' compensation benefits available, depending on the nature, date, and severity of the worker's injury: (1) medical care, (2) temporary disability benefits, (3) permanent disability benefits, (4) vocational rehabilitation services for injuries that occurred before January 1, 2004, (5) supplemental job displacement benefits for injuries that occurred after January 1, 2004, and (6) death benefits.
Medical Care
Injured workers are entitled to receive all medical care reasonably required to cure or relieve the effects of the injury, with no deductible or co-payments by the injured worker. For dates of injury on or after Jan. 1, 2004, an injured worker is limited to 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits.
The JPA has established a Medical Provider Network (MPN), WellComp, for the provision of all medical care and medical services related to a work related injury occurring on or after October 1, 2005. All employees, volunteers and ROP Students are covered by the MPN. However, if the employee has notified the employer in writing prior to the injury that he or she has a "personal physician" on the Personal Physician Designation form (see Appendix A), the employee may be treated by that physician from the date of injury. A “personal physician” for workers’ compensation must be a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.), or group comprised of the same who has limited his or her practice of medicine to general practice or who is a certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner.
Further, the personal physician must be the employee’s regular physician who has previously directed the employee’s medical treatment and retains the employee’s medical records and medical history. A personal physician cannot be a chiropractor or an acupuncturist.
Following an injury and employee will be directed by his/her employer to an initial care provider within the WellComp MPN and can thereafter change providers by selecting another provider within the WellComp MPN. The MPN includes providers from all specialties including chiropractic medicine and acupuncture. The list of participating providers can be accessed via internet at www.wellcomp.net or an employee can receive a hard-copy of the most current list of providers by contacting YORK Risk Services Group, Inc.
Temporary Disability Benefits
Those workers unable to return to work within three days1 are entitled to temporary disability benefits to partially replace wages lost as a result of the injury (workers’ compensation benefits are generally designed to replace two-thirds of the lost wages, up to a statutory maximum). Eligibility for temporary disability benefits is determined by the authorized treating physician. An employee may not be eligible for temporary disability benefits if transitional duty is available that accommodates any temporary restrictions imposed by the treating physician.
After the day of injury, eligibility for temporary disability benefits begin on the fourth calendar day the employee cannot work as authorized by the employee’s treating physician within the WellComp MPN, unless a pre-approved Personal Physician Designation form is on file – see Appendix A). By law, the three-day period is waived if the injury results in immediate hospitalization or the employee is off work for more than 14 days.
Note that the member agency, in accordance with the Education Code and its own memorandums of understanding (MOU) will supplement temporary disability benefits so that injured workers receive full pay during Industrial Accident Leave, including the first three days following the injury. If leave extends beyond 60 working days employees are entitled to supplement the temporary disability benefits with regular sick leave, extended sick leave, and other benefits depending on their position and the Member Agency MOU. (See “Supplementing Temporary Disability Benefits” below)
1
California Labor Code §4652. Temporary disability indemnity is not recoverable for the first three days after the employee leaves work as a result of the injury unless temporary disability continues for more than 14 days or the
Permanent Disability Benefits
Injured workers who are permanently disabled are entitled to receive permanent disability benefits. A worker who is determined to have a permanent total
disability receives the temporary disability benefit for life.
A worker determined to have a permanent partial disability receives partial benefits for a certain period. The length of the period is based on the worker’s medical condition, date of injury, age when injured, and occupation, and loss of future earning capacity.2
Vocational Rehabilitation Services
Vocational rehabilitation services are not available for injuries on or after Jan. 1, 2004. For injuries prior to that date, injured workers who are unable to return to their former type of work are entitled to vocational rehabilitation services if these services can reasonably be expected to return the worker to suitable gainful employment. Vocational rehabilitation does not apply to injury after Jan. 1, 2004.
Supplemental Job Displacement Benefits
This is a nontransferable voucher for education-related retraining or skill enhancement, or both, payable to a state approved or accredited school if the worker is injured on or after Jan. 1, 2004. The employee must have suffered a permanent disability and the employer does not offer modified or alternative work. Employees injured between 1/1/2004 and 12/31/2012, the amount of the voucher varies from $4,000 to $10,000, depending on the permanent disability level. Employees injured on or after Jan. 1, 2013, the voucher amount is $6000 for all permanent disability ratings.
Death Benefits
In the event a worker is fatally injured, reasonable burial expenses, up to $5,000, are paid for injuries prior to 1/1/2013, and up to $10,000 for injuries on or after 1/1/2013. In addition, the worker's dependents may receive support payments for a period of time, depending on the extent of their dependency, subject to a statutory maximum.
Supplementing Temporary
Disability Benefits
Overview
Temporary disability benefits are one of the six workers’ compensation benefits described in the previous section. Temporary disability benefits provide two-thirds of the employee’s normal salary up to maximum amount determined by the State of California. Temporary disability benefits continue through the period of disability up to a maximum number of weeks according to the date of injury.
Employees of public educational institutions who are subject to the California Education Code are entitled to additional benefits during a workers’ compensation leave that vary for each agency depending on the terms of the its MOU and on past administrative practice. However, in general, during the employee’s entitlement to temporary disability, there are different types of supplemental benefits provided to the employee to increase the employee’s compensation. The timeline below is an example of the continuum of supplemental benefits but will vary depending on the agency’s MOU and past administrative practice.
Industrial Accident Leave
Once a claim is pending or accepted, the Member Agency continues to pay the employee a regular payroll checks during Industrial Accident Leave. Industrial Accident Leave is the 60-day period following the employee’s first day of absence. YORK Risk Services Group, Inc. will reimburse the Member Agency out of the VCSSFA funds for the workers’ compensation temporary disability benefits included in the employee’s salary.
Industrial Accident Leave Sick Leave Vacation Ext. Sick Leave 39-rehire
1st day 60 100 days for classified 39
absent days employees; 5 months for months
certificated employees* Family Medical Leave Act runs concurrently (12 weeks)
Industrial Accident Leave applies for 60 working days for any one accident or illness during any one fiscal year, except that when an industrial accident or illness leave overlaps into the next fiscal year, the employee is entitled to only the amount of unused leave due for the same injury or illness. Industrial Accident Leave is not cumulative and begins on the first day of absence. Employees are eligible to receive Industrial Accident Leave at the beginning of the second month following their probation period.
Accrued Sick Leave and Accrued Vacation Leave
Once the Industrial Accident Leave has run, the Member Agency applies accrued and vested sick leave and vacation days (if applicable) to supplement temporary disability benefits in order to provide the employee with a full paycheck. The Member Agency issues the employee a full check, and YORK reimburses the Member Agency out of VCSSFA funds for the workers’ compensation portion.
An employee, who is receiving temporary disability payments and supplemental sick leave or vacation leave benefits, is considered to be on regular pay status for purposes of application of all Member Agency personnel policies except completion of the probationary period.
Extended Sick Leave
If an employee is not medically able to reassume job duties after exhausting sick leave and other selected leave accruals, the employee is then eligible to receive Extended Sick Leave. Due to the substantial variations from member agency to member agency, extended sick leave will not be detailed. During the extended sick leave period, the employee is entitled to receive both the workers’ compensation temporary disability and the benefits the member agency are obligated to pay in accordance with its extended sick leave policy. Should the combination of benefits exceed the employee’ regular earnings, YORK will coordinate the payments with the member agency to avoid an overpayment.
39-Month Rehire List
If the employee continues to be off work beyond the period of extended sick leave, and the employee is not placed in another position, the employee will be placed on a re-employment list for a period of 39 months.
Prior to the actual termination of benefits, the member agency will engage in the “interactive process” to identify if the employee’s disability can be accommodated pursuant to the rules and regulations promulgated by the California Department of Fair Employment and Housing (DFEHA) and the Americans With Disabilities Act (ADA). Should the member agency require assistance with this process, they can contact YORK.
When available during the 39-month period, the employee shall be employed in a vacant position in the class of his or her previous job over all available candidates subject to any seniority regulations.
An employee, who is on the 39-Month Rehire List, has been medically released for return to work, and who does not accept an appropriate position, will be dismissed.
Transitional Duty
If medically feasible, member agencies will attempt to place an injured worker who is unable to return to regular duty in a transitional work environment if it is suggested by the treating physician and can be practically accommodated by the member. Transitional Duty can consist of modification to existing job responsibilities or alternate temporary assignment that can accommodate the temporary restrictions.
The JPA recognizes the need to support the recovery of employees should they suffer a work-related injury or illness or develop an occupational disease. It is well established that recovery is accelerated when the employee continues to work. Based on this principle, the JPA strongly supports appropriate return-to-work in a transitional position.
Member agencies can contact YORK for ideas on how to effectively put together a transitional duty program.
Pre-Designating a Doctor
If an employee completes the Personal Physician Form (Appendix A) before the injury or illness takes place, the employee can use his or her personal physician to treat the injury or illness. This is called “pre-designating” the employee’s personal physician.Employees who pre-designate
If properly filed prior to an injury, an employee may treat immediately with their “personal physician” for workers’ compensation as long as he or she is a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.), or group comprised of the same who has limited his or her practice of medicine to general practice or who is a certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. Further, the personal physician must be the employee’s regular physician who has previously directed the employee’s medical treatment and retains the employee’s medical records and medical history. A personal physician cannot be a chiropractor or an acupuncturist.
When releasing the employee to secure medical care, the member agency should provide the employee with the “Treatment Authorization from” found in Appendix C to provide to his or her pre-designated physician.
Employees who do not pre-designate
If an employee does not pre-designate a doctor, the employee is directed to an initial care provider within the WellComp MPN. Each member agency works with YORK to select an initial care provider (s). Should the agency require assistance or desire to explore adding a new provider to the MPN, they should contact YORK. Each member agency should provide an injured employee with the “Treatment Authorization form” found in Appendix C when referring the employee for care.
After the initial medical evaluation, the employee can switch to an appropriate treating physician participating in the WellComp MPN of the employee’s choice if the employee still needs medical care. The new doctor must be the appropriate specialist to treat the nature of the injury or illness. The employee can obtain assistance finding the appropriate treating physician in the WellComp Network by contacting the WellComp Patient Services Department at (800) 544-8150. Alternatively, the employee can select their own physician by accessing the WellComp provider directory at www.wellcomp.net and requesting a hard copy of the directory by contacting YORK or the WellComp patient services Department.
Claims Filing Responsibilities
Employees
If an employee is hurt on the job, the employee should:
1. Report the injury to the employee’s supervisor immediately. If the injury or illness developed over time, the employee must report it as soon as he or she learns that it was caused by the employee’s job.
2. Get emergency treatment if needed. If it is a medical emergency, the employee should go to an emergency room right away. The employee should tell the health care provider that the injury or illness is job-related.
3. Fill out and sign the employee section of the claim form entitled Employee’s Claim for Workers’ Compensation Benefits (see Department of Workers’ Compensation (DWC) Form 1 in Appendix B) and give the completed form to his or her supervisor.
4. The supervisor fills out and signs the employer portion of the claim form and directs it internally so that it gets routed to VCSSFA claims administrator, YORK Risk Services Group, Inc.
a. YORK must decide within 90 days whether to accept or deny the claim. If YORK accepts the claim, it means that YORK agrees that the employee’s injury is covered by workers’ compensation. If YORK denies the claim, the employee has the right to challenge the decision.
5. Within one working day after the employee files the claim form, YORK, on behalf of the member agency, is required by the California Labor Code to authorize medical treatment3 up to a maximum of $10,000 while the employee’s claim is being investigated following notice or service of the claim form upon the Member Agency. If YORK does not respond to a request for authorization in a timely manner as outlined in Labor Code section 4610, the employee should notify the Business Services Office or their claims contact at YORK.
6. If an employee has filed a claim, the employee can call YORK for specific questions about his or her filed workers’ compensation claim.
7. The employee should provide his or her supervisor with all physical therapy status sheets and work status reports. Supervisors should immediately forward this information internally based on the member agency’s protocols.
8. If the employee pays a bill, the employee should photocopy the receipt and forward a copy to YORK for reimbursement. Similarly, if an injured employee receives a bill, it should be forwarded directly to YORK.
9. The employee should keep his or her supervisor informed of the status of his or her injury and claim.
10. The employee should try to schedule doctor appointments and/or physical therapy visits after work. Any doctor appointments or physical therapy treatments taken during regular work hours will result in a full day being deducted from the 60 days of Industrial Accident Leave.
Employers
If an employee reports an injury or illness to his or her supervisor, the employer must:
1. Obtain needed medical care for the injured employee right away.
a. When an employee reports an injury on a weekday during business hours and is able to transport him or herself:
1. Complete a Treatment Authorization Form (Appendix C).
2. Refer the employee to the designated WellComp initial care provider
3. If the employee has pre-designated a personal physician and it is not an emergency, the employee should go to his or her personal physician.
b. If an employee is in need of immediate medical treatment, call 911. No treatment authorization is needed.
c. Provide the injured or ill worker with DWC Form 1 (Appendix B) and the WellComp Informational Pamphlet (Appendix H) directly or send them by first class mail to the employee’s home. The injured or ill employee must be given the form within one business day of the employee’s report of the injury. The employee completes the employee section of DWC Form 1.
d. Once the employee returns the DWC 1, the employer must complete the following items:
i. Item 9 –Employer: Insert your agency’s official name
ii. Item 10 – Address: Insert your agency’s official address
iii. Items 11-13: Insert the applicable claim information.
iv. Item 16 – Signature: Sign the form.
v. Item 17 – Title: Insert your title.
vi. Item 18 – Insert your telephone number.
2. Complete the Employer’s Report of Occupational Injury or Illness (Appendix D) and fax of mail to YORK. Member agencies can also report claims to YORK via their web-based reporting portal. Contact YORK for a log-in and password.
3. Mail or fax a copy of the completed Employee’s Claim for Workers’ Compensation Benefits Form (DWC Form 1) (Appendix B) to YORK. The submission of this form does not mean that the claim is automatically accepted.
4. Report any change in an injured employee’s status to YORK immediately. A change in status would be a change in lost time from work, return to work, or a physician’s report recommending modified work duty.
5. Forward any physical therapy status sheets and work status reports received from the employee to YORK.
6. Work with YORK to provide the employee with transitional duty if the employee is unable to return to full duties following the injury.
Member agencies should also ensure that posters giving notice of workers’ compensation benefits are posted in conspicuous locations. A sample poster is shown in Appendix F. YORK will also contact member agencies to secure proof of the employee’s actual earnings. The member agency can provide a computerized or electronic summary of earnings or use the Wage Statement Form in Appendix E. It is important that these posting notices contain the language and information regarding use and access to the WellComp MPN.
As the employer, member agency’s will need to cooperate with YORK and provide them with the information necessary to investigate questionable claims and to efficiently and promptly provide the benefits to which legitimately injured employees are entitled. Should a member agency suspect that an employee or medical provider is intentionally misconstruing facts in order to get benefits that they would not otherwise be entitled, immediately notify YORK so that they can initiate a report to the proper authority for suspected Fraud.
Investigations & Sub-rosa
California Code of Regulations Section 10109(a) states that in order to comply with requirements of the Labor Code and the Administrative Director's regulations, a Claims Administrator must conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for a workers' compensation benefit. The Department of Insurance also requires that examiners be trained on an annual basis to identify suspected
insurance fraud, making your YORK examiner the most qualified to a file for a surveillance level investigation. When your examiner refers the files on your behalf, it limits the District’s
exposure to possible civil claims of malicious prosecution, slander or libel due to a violation of Civil Code Section 1708.8.
Oc-Med Program
Injury Prevention Program
The members of Ventura County Schools Self-Funding Authority currently participate or have the ability to utilize The OC-MED Injury Prevention Program. The goal of Injury Prevention and Management Services is to reduce injuries and their related costs for all members and to provide pre and post injury support to employees. The OC-Med Program and Ergonomic Intervention Services are designed to help provide a safe and healthy work environment, create an incentive for personal responsibility, provide cost savings and increase employee morale by potentially changing “work place perceptions”.
The VCSSFA Risk Program Dept. administers the OC-MED Injury Prevention Program, with services provided in close coordination with approved program vendors. The goal of The OC-MED Injury Prevention Program is designed not only to reduce the costs associated with injuries and workers’ compensation claims, but even more significant implications for efficiency, productivity, safety and health concerns amongst employees. To bring new ideas to the workplace, meet Cal/OSHA Guidelines & Standards and to learn good safety and health practices that employees will be able to implement not only at the workplace, but in everyday life, as well.
The services offered through OC-MED Injury Prevention Program vary based upon the specific needs of each referral and may include but are not limited to the below list:
1. Ergonomic Jobsite Analysis:
This entails the physical therapist visiting the work site in question to examine the employee’s job responsibilities, their work environment, worker techniques and related contributing issues. The purpose is to identify the various risk factors that are causing the injury or potential injury, and the associated costs, and then to provide
corrective recommendations in a comprehensive report. Finally, there will be close integration with VCSSFA Risk Program Coordinator, the provider of Ergonomic Evaluation and the Risk Manager to discuss and suggest viable changes needed for the employee.
2. Ergonomic Educational Program:
On-site educational programs will cover topics to enhance a successful injury prevention and management process. For example, specific target sessions for problems relating to workplace fatigue, providing preventative stretching exercises, ergonomic team set-up, a proactive attitude in management, and introduction of the "Professional Industrial Athlete" concept to the employee.
3. Follow-up Sessions:
Many of the client interventions detailed above will require closely monitored follow-up and subsequent on-site work site visits to ensure objective, successful results. The client interventions available in the Injury Prevention and Management portion of the OC-Med Program are designed to be initiated by both the client and VCSSFA on a Post and Pre-Injury basis. All client interventions will be scheduled and monitored by VCSSFA Risk Program Coordinator.
4. Training Sessions:
On-site Group Training Programs are also available and coordinated with the Risk Program Coordinator. Training is carefully customized for the occupation and the job responsibilities of those employees being trained.
A. Warm-Up Program
B. Lumbar / Abdominal Core stabilization Program C. Stretching
D. Materials Handling
E. Maintenance, Grounds & Warehouse F. Custodial
G. Para Educators H. Nutritional Services I. Office Workers J. Transportation
Sample Referral and OC-MED Injury Prevention Program informational needs are found in Appendix G along with assessment follow-up forms.
If you may have any questions, please contact Russ Olsen, Risk Program Coordinator for VCSSFA at 805.383.1970. Alternatively, you may e-mail to [email protected].
Denied Claims
If a claim is denied, YORK will confer with the member agency first and then will mail a letter to the employee’s home explaining why the claim has been denied. Copies of the letter will also be sent to the Member Agency. If the employee is still disabled but it is not work related then the member agency needs to provide the employee with the regular benefits that they would be entitled to absent a work related injury.Appendix A
Appendix B
California Department of
Workers’ Compensation
Appendix C
Employer: ___________________________________ Date ________________
Date of Injury: ___________________ Time In __________ Time Out __________
Dr. ______________________________ Address _______________________________________________
We are sending __________________________________ ____________________ to you for consultation (Injured Employee) (Title)
and evaluation in accordance with the terms of the Workers’ Compensation laws. Should you find that the injured worker requires treatment, please contact York’s Utilization Review Department at (951) 892-7200 for authorization.
_______________________________________ Department Referral (Signature)
Please submit your Doctor’s First Report to: YORK Risk Services Group, Inc., PO Box 619079, Roseville, CA 95661
Please indicate below whether or not the employee will be able to engage in his/her usual and customary occupation during the time of this injury. Should the employee be temporarily disabled from said occupation, we request you provide any and all restrictions causing him/her to be unable to perform his/her usual and customary duties. The employer provides modified light duty, when feasible, until he/she can return to his/her usual and customary duties, or is declared permanent and stationary.
Is working and not disabled from work.
Is DISABLED UNTIL _____________________________
Is released to return to regular work on _______________________
Is released to return to modified work on ______________________ WITH RESTRICTIONS of:
No pushing, pulling or lifting over 10 lbs. 15 lbs. 25 lbs. 50 lbs. _____ lbs.
No soiling or wetting of dressing and/or wound.
Limited use of Right Left Arm Shoulder Hand Wrist
Limited Standing Walking Sitting Stooping Bending
No climbing Stairs Ladders No overhead work Sitting work only
ALL MODIFIED WORK INCLUDES THE RESTRICTION OF NO SPORTS ACTIVITY.
Is scheduled to return to physician on ___________________ at __________________.
Anticipated duration of the MODIFIED status above is __________ day’s __________ weeks.
_____________________________________________________ _______________________
Physician’s Signature Date
Appendix D
Employer’s Report of
Appendix E
Appendix F
Workers’ Compensation Notice
and OSHA Safety Notice Posters
Appendix G
OC-Med Referral Information
and Ergonomic
OC-Med Injury Prevention Program Referral Information Below is information that is needed and useful in order for the OC-Med Risk Program Coordinator to schedule an Ergonomic Intervention or an Ergonomic Training Presentation.
Individual Ergonomic Intervention:
• Name of employee • Position/Job Title • Job responsibilities • Location
• Phone number and extension – work, home, cell • Best time to contact employee
• E-mail address
• Reason for scheduling an intervention; new workstation, remodel, new or change of position, complaints and or issues
• What are the issues or problems the employee believes are associated with his workstation and or job duties
• Pre Injury Intervention or Post Injury Intervention
• If Post Injury – nature of injury, diagnosis, work restrictions, work status • History of claims filed
• Urgency of the request
• Contact person to schedule the intervention (employee, supervisor, manager) • Contact person’s phone number
• Request of ergonomic equipment/supplies
• Authorization for purchase of an ergonomic equipment/supplies • Employee requested ergonomic evaluation
• How many workstations/worksites does the employee have • Has a previous ergonomic intervention been conducted
• Has employee been provided with ergonomic equipment/supplies through a previous intervention • Has the employee requested a particular item; such as a chair, flat screen monitor, wireless
headset, etc.
• Employee’s emotional and behavioral status (perception of need)
• Any additional information in which the OC-Med Risk Program Coordinator and the Physical Therapist should be aware of prior to contacting the employee and conducting the evaluation
Ergonomic Training Presentation for a department or a group of employees:
• Contact person
• Contact person’s e-mail address, phone number and extension • Department
• Location of the training
• What kind of training is needed/requested • Time frame for scheduling
• How many employees will be in attendance
• Any particular ergonomic issues or problems which need to be addressed during the training program
ERGONOMICS ASSESSMENT
Prevention Early Intervention Post Injury Name:
Sex: M F Height:
Job Title: Dept #:
Phone #: Email #:
Date of Evaluation:
Dominant Hand: Right Left Corrective Lenses? Yes No Type: Contacts Bifocals
Supervisor: Supervisor’s email:
Date of Hire:
Work hours/schedule: Commute time to work:
Overtime: Yes No Hours:
Lunch/Breaks: Yes No Frequency:
Job Duties:
Please provide some information regarding the frequency of your work tasks using the following (please circle):
Never Rarely Occasional Frequently Constantly
(0 - 10% of the shift) (up to 33% of the shift) (34 - 66% of the shift) (67 – 100% of the shift)
1. Computer use: N R O F C
2. Numeric keypad use: N R O F C
3. Inputting info. from documents: N R O F C
4. Telephone use: N R O F C
5. Handwriting: N R O F C
Please provide information regarding any current physical discomfort levels (optional):
Never Rarely Occasional Frequently Constantly
(0 - 10% of the shift) (up to 33% of the shift) (34 - 66% of the shift) (67 – 100% of the shift)
1. Hand/wrist discomfort: N R O F C
2. Shoulder/arm discomfort: N R O F C
3. Neck discomfort: N R O F C
4. Back discomfort: N R O F C
5. Hip/leg discomfort: N R O F C
Please elaborate on areas of discomfort noted above:
____________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________
Please describe any non-functioning equipment (i.e. chair broken, keyboard tray not working, mouse sticks):
____________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________
What do you like/dislike about your workstation?
____________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________
Off-Work Activities:
Hobbies/Recreation: _______________________________________________________________________________________ Computer use at home: _______________________________________________________________________________________
Identify equipment currently used:
______________________________________________________________________________________________________________________
Training Section:
The employee was instructed in how to adjust the chair: Yes No N/A
The employee was instructed in how to adjust the keyboard platform: Yes No N/A The employee was instructed in work pacing and rest pause techniques: Yes No N/A The employee has completed ergonomics training (classroom or online): Yes No N/A
RISK FACTOR ASSESSMENT:
Risk Factor Affected Areas Problems/Issues Recommendations Equipment Implementation
Awkward Postures
Repetition
Contact Stress
Environment
