ELGIN LOCAL SCHOOLS. WORKERS COMPENSATION MANUALS AND FORMS For Elgin Administration

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1 ELGIN LOCAL SCHOOLS WORKERS COMPENSATION MANUALS AND FORMS For Elgin Administration Revised May

2 ELGIN LOCAL SCHOOLS BUREAU OF WORKER S COMPENSATION CLAIM INSTRUCTIONS The Following steps must be completed after an accident or injury has occurred. Paperwork should be filled out before the end of the shift of the occurrence, if this is not possible, it must be completed within 24 hours. Employee: Complete the required form Employee Incident/Accident Report. Return this form to your Supervisor/Principal immediately. Complete the required form Back Injury Report if applicable. When you arrive to the medical facility where you are being treated, you must have them file a FROI- (First Report of Injury). This will trigger a BWC (Bureau of Workers Compensation) Claim Number. Be sure to let your healthcare provider/emergency room know the name of the Managed Care Organization (MCO) of your employer; if this is not done, the medical bills will be sent to you and payment will be delayed. Comp Management, Inc. PO Box 884 Dublin, Ohio Phone Fax Website Supervisor or Direct Report: Employee must be given all required paperwork to start a BWC claim. Complete the required Supervisor s Investigation Report Complete the required Statement of Witness to Accident if applicable. Give employee a copy of the Elgin Local School District Bylaws & Polices in regards to accident or injury. Workers Compensation Coordinator: Your Workers Compensation Coordinator (Treasurer) will call Comp Management, Inc., the BWC certified Manager Care Organization, to report your injury if medical treatment is necessary. 2

3 Follow-up procedures: Call the Treasurer s office to report whether you have missed any days of work due to the injury. Please keep the following in mind: If you have not returned to work by the third day, you must contact Kim Reynolds, Treasurer to clarify pay issues. If you have not returned to work and not called Kim, we will assume your absence has nothing to do with your accident. If you receive any medical bills related to your claim, please call the medical provider that billed you and tell them to re-bill: Comp Management, Inc. PO Box 884 Dublin, Ohio Phone Fax Website Please keep Kim informed of further problems, medical treatment, or additional missed days due to the injury/claim. Elgin Local Schools Kim Reynolds, Treasurer, Workers Compensation Coordinator Phone Fax Revised 04/23/2014 3

4 EMPLOYEE OCCUPATIONAL INCIDENT REPORT This report is to be completed by Elgin Local School employees when an occupational (work-related) illness or incident occurs. Social security number: Name (print): Sex Male Female Home Address: City: Zip: Home Phone: Work Phone: Location: Job Title: Supervisor Name: Phone No. DOB Date of Incident: Time of Incident: Were you performing regular duties at the time of Accident? Yes No Did anyone see you get hurt? Yes No Did you report this incident to anyone? Yes No If so, who? State all parts of body and type of injuries involved (e.g. bruised right elbow) Describe how incident occurred: Have you ever experienced a similar injury? Is this an aggravation of a previous Injury? Yes No Do you require medical treatment for this injury? No medical treatment Declined treatment at this time Treatment was/will be provided by: Name (facility or physician): Medical Release Under current Worker s Compensation Law, the employer is entitled to signed medical release. I hereby authorize any person or persons who have in the past or will in the future medically attend, treat or examine me, or any person who may have information of any kind which may be used to reach a decision in any claim for injury or disease arising from the injury illness described above, to disclose such information to my employer, my managed care organization, or designated representative. A copy of this form will serve as the original. Date: Signature of employee: Revised 04/23/2014 4

5 EMPLOYEE BACK INJURY REPORT This report is to be completed by Elgin Local School employees when an occupational (work-related) illness or incident occurs. Social security number: Name (print): Sex Male Female Home Address: City: Zip: Home Phone: Work Phone: Building: Job Title: Supervisor Name: Phone No. DOB What part of your back hurts know? When did you first notice the pain? If you were lifting an object what was it and how heavy was it? Did anyone see you get hurt? Yes No If so, who? Have you been treated for a back injury before? Yes No If so, when? Is this an aggravation of a previous Injury? Yes No If yes, when were you treated for the previous injury? Have you ever received compensation because of a back injury? Do you require medical treatment for this injury? No medical treatment Declined treatment at this time Treatment was/will be provided by: Name (facility or physician): Medical Release Under current Worker s Compensation Law, the employer is entitled to signed medical release. I hereby authorize any person or persons who have in the past or will in the future medically attend, treat or examine me, or any person who may have information of any kind which may be used to reach a decision in any claim for injury or disease arising from the injury illness described above, to disclose such information to my employer, my managed care organization, or designated representative. A copy of this form will serve as the original. Date: Signature of employee: Revised 04/23/2014 5

6 SUPERVISOR OCCUPATIONAL INCIDENT REPORT Supervisor of injured Elgin Local School employee must complete and FAX this page to the District Workers Compensation Coordinator ( Kim Reynolds) at : Supervisor Name: Work Phone: Building: Name of injured employee: Date of Incident: Time of Incident: Job Title: Where did this event happen? Address/Bldg. or room #of incident: Did employee lose time from work after date of injury? Yes No Unknown If yes last day worked Date employee returned to work In your words, describe what happened? State all parts of body and type of injuries involved (e.g. bruised right elbow) To your knowledge did this injury/illness involve the influence of drugs or alcohol? Yes No Was the employee treated in a medical facility? Yes No Was the employee killed as a result of the accident? Yes No Was the injury the result of horse play? Yes No Date: Signature of employee: Revised 04/23/2014 6

7 STATEMENT OF WITNESS TO ACCIDENT Supervisor of injured Elgin Local School employee must complete and FAX this page to the District Workers Compensation Coordinator ( Kim Reynolds) at : Supervisor Name: Work Phone: Your Name Title Position Your name has been given as a witness to an incident alleged by an individual. Through your cooperation, information can be obtained to complete the investigation of this incident: Name of injured employee: Where did this event happen? Address, building, name & room # of incident: Did you see an accident involving the above employee? Yes No If yes, please state the Date and Time. Date Time In your words please describe what you saw? Signature Date Revised 04/23/2014 7

8 Elgin Local School District Bylaws & Policies Workers' Compensation The Ohio Bureau of Workers' Compensation (BWC) provides insurance coverage to employees for workrelated injuries sustained in the course of and arising out of employment and diseases contracted in the course of employment. It also provides benefits to employees' dependents in those cases of death suffered in the course of and arising out of employment. To that end, if an employee sustains a workplace injury or contracts an occupational disease, s/he may be eligible to receive compensation and benefits under the Workers' Compensation Act for loss sustained on account of an injury or illness. A. Reporting A Work-Related Injury 1. A Board employee who sustains a work-related injury must report the injury and its circumstances to the building principal or job supervisor, as appropriate, as soon as possible following the occurrence of the injury. A First Report of Injury, Occupational Disease or Death application ("First Report of Injury" or "FROI-1") must be completed and an accident investigation will be conducted in a timely manner. The failure of an employee to comply with this requirement may result in disciplinary action (see Policy 8442). 2. In addition to reporting the injury and completing an incident/accident report, the employee may file an application for benefits with the BWC. The Superintendent's designee will provide assistance to an employee in filing a workers' compensation claim. 3. Payment for related medical benefits is the responsibility of the Board's Managed Care Organization (MCO) and the BWC. B. Leave Status Loss-Time Claim 1. If an employee sustains a work-related injury and is unable to perform the functions of his/her position, s/he may file a workers' compensation claim in order to receive compensation and benefits through the BWC. Competent medical proof of disability must be completed by the attending physician using the proper form and affixing his/her original signature. The injury or illness must be determined to be compensable by the Board, or in the case of dispute, the Ohio Industrial Commission. In no event will compensation commence before all initial paperwork is completed and filed with the appropriate agency. a. An employee may apply for the use of sick leave pending approval of his/her workers' compensation claim. However, upon approval of the claim the employee shall reimburse the Board for any and all payments received in excess of his/her regular rate of pay. b. An employee may apply for an unpaid leave of absence pending approval of his/her workers' compensation claim. c. If an employee sustains a work-related injury, is unable to perform the functions of 8

9 his/her position and does not choose to file a workers' compensation claim, s/he may apply for the use of sick leave. 2. An employee may be simultaneously placed on leave under the Family and Medical Leave Act during his/her leave of absence as a result of a work-related injury or illness in accordance with Board policy. C. Board The Board reserves the right to have the employee examined by a physician of its choice at the Board's cost to confirm the medical diagnosis and/or the period of disability. Failure to submit to examination will result in termination of wage continuation benefits. An employee who obtains compensation from the BWC by knowingly misrepresenting or concealing facts, making false statements or accepting compensation to which s/he is not entitled, is subject to felony criminal prosecution for fraud (see R.C ). R.C R.C. Chapter 4123 A.C

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