Reporting Instructions for LIBC-344 Employer s Report of Occupational Injury or Disease IMPORTANT INFORMATION:

Transcription

1 Reporting Instructions for LIBC-344 Employer s Report of Occupational Injury or Disease All work related injuries/incidents should be reported to your supervisor and the Office of Human Resources immediately. The Employer s Report of Occupational Injury or Disease (form LIBC-344) should be completed even if medical treatment is not necessary. Employer s Report of Occupational Injury or Disease (Form LIBC-344) Injury Report must be completed (front and back) and returned to Shari Heffner in the Office of Human Resources, Room 118 Alumni Hall. Injury Reports can be faxed to (570) Instructions on completing the Injury Report are included. IMPORTANT INFORMATION: MEDICAL TREATMENT FOR YOUR WORKPLACE INJURY: If you need medical treatment, you MUST be treated by a Panel Physician for the first 90 days of treatment. Payment for services provided by a non-panel provider during this 90-day period will be your responsibility unless you receive a referral from a panel provider. CLAIM NUMBER: A claim number cannot be assigned until an injury report is received. When receiving treatment for your injury you will need to give your claim number to your provider. All medical claims related to your injury must be sent to: Inservco Insurance Service, Inc. Two North Second St. P.O. Box 3899 Harrisburg, PA QUESTIONS: Questions regarding Injury Reports and Workers Compensation issues should be directed to Shari Heffner, 118 Alumni Hall, (570)

2 Employer s Report of Occupational Injury or Disease (Injury Report) Completion Instructions In General: The Employer s Report of Occupational Injury or Disease (Injury Report) must be completed in the event that an employee is injured as the result of a workplace accident. The Employer s Report of Occupational Injury or Disease (Injury Report) must be completed in blue or black ink or typewritten. Injury reports should be returned to the Office of Human Resources ASAP. 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 side, lower left hand corner of the form. Injury reports are electronically forwarded by the Benefits Office to Inservco, PASSHE s third party administrator for worker s compensation claims. If employee needs to seek medical treatment for their work injury they must treat with a panel provider for the first 90 days of treatment. The current Panel of Physicians is attached. If an employee is referred off panel by a panel physician, they need to contact Tammy Felondis at ext prior to seeing the non-panel physician. Completing the Injury Report: The Injury Report is two sided - complete both sides of the report. 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, fill in the corresponding numerical code and then write out the description. Information Boxes: Most of the boxes are self-explanatory. The following information is either preprinted on the form or can be left blank: NCCI Class Code Employer Employer Street Address, City, State and Zip Code SIC-Code Employer FEIN Employer Phone Number Employer County NAICS Code Contact First Name Contact Last Name Full Pay for Date of Injury Leave Blank Last Day Worked Date of injury 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 (employee absent from work): Complete this box with the date of the last day worked. A doctor s certificate stating that employee is disabled due to work injury in

3 order for 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 Date Employer Notified Date that the supervisor or other IUP administrator was informed that an injury occurred. Type of Injury Code Numerical code on Type of Injury Code table Part of Body Affected Code Numerical code on Part of Body Affected Code table Cause of Injury Code Numerical code on Cause of Injury Code table Type of Injury or Illness Fill in the type of injury corresponding with the Type of Injury Code Parts of Body Affected Fill in the part of body affected corresponding with the Part of Body Affected Code Cause of Injury Fill in the cause of injury corresponding with the Cause of Injury Code Did Injury or Illness Occur on Employer s Premises? Check 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 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. If Fatal, Give Date of Death Write in date of death. NOTE: If a workplace accident results in the death of an employee, the Benefits Office MUST be notified IMMEDIATELY. Initial Treatment Check appropriate box(es) No Medical Treatment Minor by Employee Clinic/Hospital Panel Physician Employee Physician Emergency Care Hospitalized more than 24 Hours Physician/Health Care Provider Name and address of provider of treatment for the work injury/illness. Leave blank if not applicable. Hospital Name Name and address of hospital for treatment of work injury/illness. Leave blank if not applicable. Policy/Self Insured Number Leave blank

4 Policy Period From: Leave blank Policy Period To: Leave blank Witness First Name: First name of witness. Leave blank if not applicable. Witness Last Name: Last name of witness. Attach a separate sheet if more than one witness. Leave blank if not applicable. Witness Phone Number: Witness phone number. Leave blank if not applicable. Person Completing This Form: Name of person completing the Injury Report (supervisor or employee) Date Prepared: Date this report was completed may be different from the date of injury.

5 Type of Injury Codes 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) 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

6 Part of Body Affected Codes 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 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

7 Cause of Injury Codes 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 Miscellaneous 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 Miscellaneous 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 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 - Miscellaneous 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 Miscellaneous 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

8 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 - Miscellaneous 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 Miscellaneous 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, Miscellaneous, NOC Cause of Injury Codes (cont d)