**Student Employee** Workplace Injury Reporting Instructions

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1 **Student Employee** Workplace Injury Reporting Instructions **Student Employee** Employer s Report of Occupational Injury or Disease (Injury Report) The two-page Injury Report form must be completed and forwarded to the Human Resources Office, Reeder Hall, 2 nd Floor, within five (5) days of the date of injury. Injury Reports can be faxed to (814) Instructions on completing the Injury Report are provided in **Student Employee** Employer s Report of Occupational Injury or Disease (Injury Report) Completion Instructions section provided below. See Appendix B for sample form. Witness Statement Complete the Witness Statement providing a detailed account of the incident. Complete a separate statement for each witness. Workers Compensation Employee Notification and Information Forms This is a two-page form; both pages must be signed and returned with the Injury Report. Physical Capacities Checklist Form This form should be given to the provider to complete in the event that the treating provider recommends modified or light duty. The form should be returned to the Human Resources Office. Forms can be faxed to (814) A copy will be provided to your supervisor. Important Information Medical Treatment for Your Workplace Injury If you need to seek medical treatment for your work injury, you must report to the Ghering Health Center for medical evaluation and treatment. If it is determined that more extensive treatment is needed beyond the services provided by the Ghering medical staff, you must be treated by a panel provider. If you are referred to a panel physician, you must treat with the panel provider for the first 90 days of treatment. If you are referred to an off-panel provider by a panel physician, you need to contact the Human Resources Office prior to seeing the non-panel physician. Payment for services provided by a non-panel provider during the first 90-day period will be the student employees responsibility unless a referral is received from a panel provider. Claim Number A claim number cannot be assigned until an Injury Report is received in the Human Resources Office. The student employee must contact the Human Resources Office to receive their claim number. When receiving treatment for an injury, the student employee will need to give their claim number to the provider. All medical claims/forms received from the medical provider must be returned to the Human Resources Office. The Human Resources staff will then forward all related materials to Inservco, PASSHE s third party administrator for workers compensation claims. Questions Questions regarding Injury Reports and Workers Compensation issues should be directed to the Human Resources Office, Reeder Hall, 2 nd Floor, (814)

2 **Student Employee** Employer s Report of Occupational Injury or Disease (Injury Report) Completion Instructions General Instructions: All Auxiliary Services, i.e., Chartwell s and/or University Services Inc., employees must contact their immediate supervisor for work-related injury reporting procedures. The **Student Employee** Employer s Report of Occupational Injury or Disease (Injury Report) must be completed in the event that a student employee is injured as the result of a workplace accident. Please complete in blue or black ink or typewritten. Injury reports should be returned to the Human Resources Office within five (5) days of the date of injury. A claim number cannot be assigned until the original report is returned. IMPORTANT: Do NOT mail the form to the Department of Labor and Industry as directed on the front page, lower left hand corner of the form. Injury reports are electronically forwarded by the Human Resources Office to Inservco, PASSHE s third party administrator for worker s compensation claims. If the student employee needs to seek medical treatment for their work injury, they must report to the Ghering Health Center for medical evaluation and treatment. If this is determined that more extensive treatment is needed beyond these services provided by the Ghering medical staff, student employees will treat with a panel provider. Please see the Panel Physician/Provider list. If the student employee is referred to a panel physician, the student employee must treat with the panel provider for the first 90 days of treatment. If a student employee is referred off panel by a panel physician, they need to contact the Human Resources Office prior to seeing the non-panel physician. Questions should be addressed to the Human Resources Office at (814) Completing the Injury Report: The Injury Report is two pages - complete both pages Enter all dates as MMDDYYYY Enter all times as HHMM, checking the AM or PM box, as appropriate. Do Not use military time. For the type of injury, part of body affected, and cause of injury codes sections; select the most accurate description from the code tables (See Appendix A); fill in the corresponding numerical code and the description. Information Boxes: 1. Student Employee Information: Enter the student employee s social security number (upper right-hand corner on page 1) Enter the date of injury (upper right-hand corner on page 1) Enter the student employee s first name, last name, home street address (city, sate, zip, county), and phone number Enter the student employee s gender, marital status, and date of birth Number of dependents Leave blank Enter the student employee s job title Enter student employee s work status 2. Leave the following items blank: NCCI Class Code SIC-Code Employer FEIN (Employer) Phone Number (Employer) County NAICS Code Full Pay for Date of Injury 3. Time Student Employee Began Work Enter the time the student employee began work the day of the injury 4. Time of Occurrence Enter the time the injury occurred 5. Last Day Worked Enter the date of injury

3 6. Date Disability Began - Leave blank if injury is medical only and does not involve lost time from work Date Returned to Work - If injury resulted in disability (student employee absent from work), complete this box with the date of the last day worked. A medical provider s certificate stating that student employee is disabled due to work injury must be provided in order for student employee to be eligible for compensation benefits. There is a waiting period for compensation benefits. If injury did not result in a disability (no work missed), leave blank. 7. Date Employer Notified Enter the date that the supervisor or Human Resources Office was informed that an injury occurred 8. Date Returned to Work Enter the date the student employee returned to work 9. Date of Hire Enter the student employee s date of hire 10. Injury Information (See Appendix A): Type of Injury Code Select the appropriate numerical code from Type of Injury Codes table Part of Body Affected Code Select the appropriate numerical code from Part of Body Affected Codes table Cause of Injury Code Select the appropriate numerical code from Cause of Injury Codes table Type of Injury or Illness Enter the description corresponding with the Type of Injury Code entered previously Parts of Body Affected Enter the description corresponding with the Part of Body Affected Code entered previously Cause of Injury Enter the description corresponding with the Cause of Injury Code entered previously Did Injury or Illness Occur on Employer s Premises? Check the appropriate box If Out of State, Specify State of Injury Leave blank if injury occurred in Pennsylvania Were Safeguards or Safety Equipment Provided - Check appropriate box or leave blank if not applicable Were Safeguards or Safety Equipment Used - Check appropriate box or leave blank if not applicable All Equipment, Materials, or Chemicals Student Employee was Using when Accident or Illness Exposure Occurred List any equipment, material or chemicals that were being used when the injury occurred or leave blank if not applicable How Injury or Illness/Abnormal Health Condition Occurred. Describe the Sequence of Events and Include Any Objects or Substances Directly Responsible Describe, in detail, how the injury occurred. Attach an additional sheet if necessary 11. If Fatal, Give Date of Death Write in date of death. NOTE: If a workplace accident results in the death of a student employee, the EUP Benefits Manager MUST be notified IMMEDIATELY. 12. Initial Treatment Check appropriate box(es) 13. Provider Information: Physician/Health Care Provider Fill in the name and address of treating provider or leave blank if not applicable Hospital Name Enter the name and address of treating hospital or leave blank if not applicable 14. Leave the following items blank: Policy/Self Insured Number Policy Period From Policy Period To 15. Witness Information (Attach a separate sheet if more than one witness): Witness First Name: Enter the witness first name Witness Last Name: Enter the witness last name Witness Phone Number: Enter the witness phone number 16. Person Completing This Form: Enter the name, title and phone number of person completing the Injury Report (supervisor or student employee) 17. Insurance Carrier or Third Party Administrator (If Self-Insured): Leave blank 18. Date Prepared: Enter the date this report was completed may be different from the date of injury

4 1 No Physical Injury 2 Amputation 3 Angina Pectoris Stroke 4 Burn 7 Concussion 10 Contusion 13 Crushing 16 Dislocation 19 Electric Shock 22 Enucleation 25 Foreign Body 28 Fracture 30 Freezing 31 Hearing Loss or Impairment 32 Heat Prostration 34 Hernia 36 Infection 37 Inflammation 40 Laceration 41 Myocardial Infarction (Heart Attack) 42 Poisoning General (Not OD or Cumulative Injury) APPENDIX A Type of Injury Codes 43 Puncture 46 Rupture 47 Severance 49 Sprain 52 Strain 53 Syncope (Unconscious, Faint) 54 Asphyxiation 55 Vascular 58 Vision Loss 59 All Other Specific Injuries, No Other Code (NOC) Occupational Disease or Cumulative Injury 60 Dust Disease, NOC (All Other Pneumoconiosis) 61 Asbestosis 62 Black Lung 63 Byssinosis 64 Silicosis 65 Respiratory Disorders (Gases, Fumes, Chemicals, Etc.) 66 Poisoning Chemical (Other than metals) 67 Poisoning Metal 68 Dermatitis 69 Mental Disorder 70 Radiation (welding/flash) 71 All Other Occupational Disease Injury, NOC 72 Loss of Hearing 73 Contagious Disease 74 Cancer 75 AIDS 76 VDT-Related Disease (visual terminal display) 77 Mental Stress 78 Carpel Tunnel Syndrome 79 Hepatitis C 80 All Other Cumulative Injuries, NOC Multiple Injuries 90 Multiple Physical Injuries Only 91 Multiple Injuries Including Both Physical and Psychological Head 10 Multiple Head Injury 11 Skull 12 Brain 13 Ear(s) 14 Eye(s) 15 Nose 16 Teeth 17 Mouth 18 Head Soft Tissue 19 Facial Bones Neck 20 Neck Multiple Injury 21 Vertebrae 22 Neck Disc 23 Neck Spinal Cord 24 Larynx 25 Neck Soft Tissue 26 Trachea Upper Extremities 30 Multiple Upper Extremities 31 Upper Arm (including Clavicle and Scapula) 32 Elbow Part of Body Affected Codes 33 Lower Arm 34 Wrist 35 Hand 36 Finger(s) 37 Thumb 38 Shoulder(s) 39 Wrist(s) and Hand(s) Trunk 40 Multiple Trunk 41 Upper Back Area (Thoracic Area) 42 Low Back Area (including Lumbar and Lumbo- Sacral) 43 Back Disc 44 Chest (including Ribs, Sternum and Soft Tissue) 45 Sacrum and Coccyx 46 Pelvis 47 Back Spinal Cord 48 Internal Organs 49 Heart 60 Lungs 61 Abdomen including Groin 62 Buttocks 63 Lumbar and/or Sacral Vertebrae (Vertebrae NOC Trunk) Lower Extremities 50 Multiple Lower Extremities 51 Hip 52 Upper Leg 53 Knee 54 Lower Leg 55 Ankle 56 Foot 57 Toe(s) 58 Great Toe Multiple Body Parts 64 Artificial Appliance 65 Insufficient Info to Properly Identify Unclassified 66 No Physical Injury 90 Multiple Body Parts 91 Body Systems and Multiple Body Systems

5 Burn or Scald Heat or Cold Exposure 1 Burn Acid Chemicals 2 Burn Contact with Object 3 Burn Temperature Extremes 4 Burn Fire or Flame 5 Burn Steam or Hot Fluids 6 Burn Dust, Gases, Fumes, Vapor 7 Burn Welding Operations 8 Burn Radiation 9 Burn 11 Burn Cold Objects or Substances 14 Burn Abnormal Air Pressure 84 Electrical Current Caught In or Between 10 Caught In Machinery 12 Caught In Object Handled 13 Caught In or Between 20 Caught In Collapsing Materials (Slides of Earth) Cut, Puncture, Scrape Injured By 15 Cut injured by broken glass 16 Cut injured by hand tool use 17 Cut injured by object being lifted or handled 18 Cut injured by power tool 19 Cut injured by miscellaneous Fall or Slip Injury 25 Fall or Slip from different level 26 Fall or Slip from ladder 27 Fall or Slip from liquid 28 Fall or Slip into openings 29 Fall or Slip same level 30 Slipped, did not fall Cause of Injury Codes 31 Fall or Slip fall, slip, trip NOC 32 Fall or Slip on ice or snow 33 Fall or Slip on stairs Motor Vehicle 40 Motor Vehicle crash of water vehicle 41 Motor Vehicle crash of rail vehicle 45 Mother Vehicle collision or sideswipe with another vehicle 46 Motor Vehicle collision with a fixed object 47 Motor Vehicle crash of airplane 48 Motor Vehicle vehicle upset 50 Motor Vehicle miscellaneous Strain or Injury By 52 Strain Injury by Continual Noise 53 Strain Injury by Twisting 54 Strain Injury by Jumping 55 Strain Injury by Holding or Carrying 56 Strain Injury by Lifting 57 Strain Injury by Pushing or Pulling 58 Strain Injury by Reaching 59 Strain Injury by Using Tool or Machinery 60 Strain Injury by - 61 Strain Injury by Wielding or Throwing 97 Strain Injury by Repetitive Motion Striking Against or Stepping On 65 Stepping On/Striking Moving Parts of Machine 66 Stepping On/Striking Object Being Lifted or Handled 67 Stepping On/Striking Sanding, Scraping, Cleaning Operations 68 Stepping On/Striking Stationary Object 69 Stepping On/Striking Sharp Object 70 Stepping On/Striking Struck or Injured By 74 Struck/Injured by Fellow Worker 75 Stuck/Injured by Falling or Flying Object 76 Struck/Injured by Hand Tool or Machine in use 77 Struck/Injured by Motor Vehicle Struck or Injured By (cont d) 78 Struck/Injured by Moving Parts of Machine 79 Struck/Injured by Object being lifted or handled 80 Struck/Injured by Object handled by others 81 Struck/Injured by - 85 Struck/Injured by Animal/Insect 86 Struck/Injured by Explosion or Flare Back Rubbed or Abraided By 94 Rubbed or Abraided by repetitive motion 95 Rubbed or Abraided NOC Causes 82 Misc Absorption, Ingestion or Inhalation, NOC 87 Misc Foreign Matter/Body in Eye(s) 89 Misc Person in Act of Crime 90 Misc Other than Physical Cause of Injury 98 Misc Cumulative, NOC 99 Misc Other,, NOC

6 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA (TOLL FREE) TTY (TOLL FREE) EMPLOYEE FIRST NAME EMPLOYER S REPORT OF OCCUPATIONAL INJURY OR DISEASE EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE LAST NAME STREET ADDRESS CITY STATE ZIP CODE - COUNTY PHONE NUMBER EMPLOYEE: NUMBER OF DEPENDENTS DATE OF BIRTH MALE MARRIED FEMALE SINGLE OCCUPATION OR JOB TITLE NCCI CLASS CODE (IF KNOWN) EMPLOYMENT STATUS FT = Full-time SL = Seasonal PT = Part-time VO = Volunteer ZZ = Other EMPLOYER STREET ADDRESS CITY STATE ZIP CODE - SIC CODE EMPLOYER FEIN PHONE NUMBER - COUNTY NAICS CODE FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK TIME OF OCCURRENCE YES NO AM : : PM AM PM LAST DAY WORKED DATE DISABILITY BEGAN DATE EMPLOYER NOTIFIED DATE RETURNED TO WORK DATE OF HIRE CONTACT FIRST NAME CONTACT PHONE NUMBER CONTACT LAST NAME NOTICE: Report should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee and insurer. LIBC-344 REV 1-01 (OVER)

7 LIBC 344 TYPE OF INJURY CODE PART OF BODY AFFECTED CODE CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN) TYPE OF INJURY OR ILLNESS PARTS OF BODY AFFECTED CAUSE OF INJURY DID INJURY OR ILLNESS OCCUR IF OUT OF STATE, SPECIFY WERE SAFEGUARDS OR SAFETY WERE SAFEGUARDS OR SAFETY ON EMPLOYER S PREMISES? STATE OF INJURY EQUIPMENT PROVIDED? EQUIPMENT USED? YES YES YES NO NO NO ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE. IF FATAL, GIVE DATE OF DEATH PHYSICIAN/HEALTH CARE PROVIDER FIRST NAME: LAST NAME: STREET CITY STATE ZIP HOSPITAL NAME: STREET CITY STATE ZIP POLICY/SELF INSURED NUMBER: INITIAL TREATMENT: NO MEDICAL TREATMENT MINOR BY EMPLOYEE CLINIC / HOSPITAL PANEL PHYSICIAN EMPLOYEE PHYSICIAN EMERGENCY CARE HOSPITALIZED MORE THAN 24 HOURS POLICY PERIOD FROM: POLICY PERIOD TO: WITNESS FIRST NAME WITNESS PHONE NUMBER WITNESS LAST NAME PERSON COMPLETING THIS FORM: NAME: INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED) NAME: TITLE: STREET PHONE: CITY STATE ZIP DATE PREPARED BUREAU CODE: FEIN: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.

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