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1 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 Page 1 of 7 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-mandated workers 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 workrelated injury or illness. UC Supplemental Benefits The University of California provides in addition to those mandated by law, to eligible employees. Extended sick leave benefit (ESL) is a combination of workers compensation payment and UC supplement that equals 80% of an employee s regular salary. It is available for up to 26 weeks for eligible* employees who are medically unable to return to work as a result of a workers compensation injury. (*Refer to University personnel policies and collective bargaining agreements for specific extended sick leave and vacation benefits related to "Work-Incurred Injury or Illness.")

2 Page 2 of 7 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 Accident/Injury Reporting (Employee) Notifying Workers Compensation Unit (House Supervisor) Injury/Illness Treatment (Supervisor) PROCEDURE 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 to report the injury. Employees should not delay treatment for urgent or emergency conditions if reporting the injury will result in treatment delay. B. Report the injury to UCI Medical Center Workers Compensation immediately via phone ( ) or fax ( ). 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 Injuries: Special Requirements (Supervisor/House Supervisor/Safety Officer) *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 Cal-OSHA must be notified by telephone (by law) immediately no later than 8 hours after any serious injury or death as defined above.

3 Page 3 of 7 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 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 or fax the information to 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) Fax: (714) 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 contact is the UCI Medical Center safety

4 Page 4 of 7 Accident Investigation (Worker s Compensation/ Supervisor/Employee) Worker s Compensation Forms Completing Forms 5020 (Supervisor) Officer Shereen Uyeda phone 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 ( ) will 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 to Workers Compensation after completing the following: H. Supervisors 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. 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 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 Fax the original to UCI Medical Center Worker s Compensation at

5 Page 5 of 7 2. DWC-1 Form Providing form DWC-1 (Supervisor or Worker s Compensation) 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. Worker s Compensation Forms (cont) 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 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 prior to mailing. Keep accurate documentation regarding the accident, including all corrective safety measures and the names of any witnesses. Providing Information (Supervisor) 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 J. If Octagon Risk Services indicates that a delay in a claim decision will occur, and the employee has been placed off

6 Page 6 of 7 Assisting the employee through the process (Supervisor Worker s Compensation ) work by a physician, other interim University benefits may be available to the employee through the UCI Medical Center Benefits office at The employee should always contact Workers Compensation unit as well, at , in this event. 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 workrestrictions. 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 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, Phone: Fax: Return to Work After Medical Absence (Employee) Exceptions: Many employees use the UCI Medical Center Occupational Health Clinic for treatment of their work injuries.

7 Page 7 of 7 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) (Employee/Supervisor ) 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 Governing Body November 24, 2003

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