1 Injured Employee Workers Compensation Guidelines To be followed by the injured or ill employee Name of Employee: Date of Work Related Injury or Illness: Description of Injury or Illness: Location Where Injury or Illness Occurred: If you experience a work related injury or illness, it is important that you follow the guidelines below. It is suggested that you date each item to document when you complete each task, as appropriate. If you have any questions about these guidelines, please call the UTD Workers Compensation (WC) Claims Analyst during regular working hours or leave a voice mail message and your call will be returned as soon as possible. The WC Claims Analyst can be reached at or You are advised to pay very close attention to the reports forms you must submit and to the timelines indicated. UTD can be fined up to $25,000 for every report form that is not received by the Division of Workers Compensation within specific timelines that have been established by law. A fine of $25,000 can be assessed against UTD for each and every violation. It is the responsibility of the UTD Claims Analysts to electronically submit the information received from the program supervisors within the established timelines, so full cooperation is expected from each supervisor. Please be aware that every fine that is received by UTD for failure to submit any of these reports in a timely fashion may be passed along to the program that failed to submit the required information to the UTD WC Claims Analysts.
2 Injured Employee Workers Compensation Guidelines 1. Notify Your Supervisor: Notify your supervisor immediately regarding when, where and how your job related injury or illness occurred. 2. Medical Treatment Authorization To Provide Services Form If you need medical care because of your work related injury or illness, you can go to any physician or clinic of your choice that accepts Workers Compensation cases. You might consider going to one of the CareNow clinics in the area. UTD has a positive working relationship with them. You will need to present an Authorization To Provide Services form and your UTD Identification Card to your medical provider. You can get an Authorization to Provide Services form from the UTD Workers Comp Claims Analyst by calling or You are not required to submit a co payment for your medical treatment by any clinic or physician offering treatment for a work related injury or illness. 3. Employee s First Report of Injury Complete the Employee s First Report of Injury form as soon as possible and give it to the UTD Claim s Analyst preferable within 24 hrs. of the incident. You can get a copy of this form from your supervisor or from the Workers Compensation Claims Analyst at UTD by calling or
3 4. Reimbursement For Medical & Pharmacy Services You may tell all medical and pharmacy providers that you use to treat your work related injury to send their bills directly to our insurance carrier at: The U.T. System P. O. Box Dallas, Texas Office: ( ) Fax: ( ) If you are required by the medical or pharmacy to pay for their services at the time you receive them, please contact your UTD Claims Analyst at or for information on reimbursement from U.T. System. You must present your original payment receipts in order for your request to be considered for reimbursement. 5. Over the Counter Medication Reimbursement If your physician orders an over the counter medication for you, a copy of your original hand written script and receipt for payment is required in order for reimbursement to be considered. You may bring your payment receipt and original hand written script to the WC Claims Analyst at UTD who will submit them to U.T. System for you. U.T. System personnel will mail your reimbursement check to your home address that is reflected on the Employer s First Report of Injury or Illness that was submitted to the WC Claims Analyst right after your injury or illness.
4 6. Time Off Work If your physician orders you to stay off work because of your work related injury or illness, you must tell your supervisor right away. You must also present your supervisor with a copy of the Work Status Report from your physician that reflects his or her order for you to stay off work. (*) It is important that you call your supervisor on a regular basis while you are off work. This is very important because you are still subject to UTD Policies and Procedures. 7. Request For Paid Leave If you are going to lose time from work because of your work related injury or illness, your supervisor will need you to complete and sign a Request for Paid Leave form. You can get this form from your supervisor, or the WC Claims Analyst. IF YOU CHOOSE TO USE PAID LEAVE, THEN YOU MUST FIRST EXHAUST SICK LEAVE. ONCE YOUR SICK LEAVE HAS BEEN EXHAUSTED, YOU MAY THEN CHOOSE TO USE ONE OR MORE WEEKS OF OTHER LEAVE IN LIEU OF RECEIVING TIBs. PRIOR TO MAKING AN ELECTION CONCERNING THE USE OF ACCRUED LEAVE, PLEASE BE ADVISED THAT ALTHOUGH THERE IS A SEVEN DAY WAITING PERIOD WHERE TIBs ARE NOT PAYABLE, SHOULD DISABILITY EXTEND TO THE 14TH DAY AFTER THE FIRST DAY OF DISABILITY, THE CARRIER WILL THEN ISSUE A TIBs PAYMENT FOR THE WAITING PERIOD. You must complete and sign the Request for Paid Leave form as soon as you can because your supervisor is required to fax this form to the WC Claims Analyst within 24 hours after you begin to miss time from work. The WC Claims Analyst provides this information to the U.T. System Workers Compensation Claims Adjuster who needs need this information as soon as possible in order to manage your lost time claim appropriately.
5 8. Work Restrictions & Follow Up Appointments If your physician orders work restrictions for you, it is important that you carefully follow your restrictions; at work and at home. It is also important that you show up for all of your physician ordered followup medical and/or physical therapy appointments until you receive a full duty work release from your physician. When you follow your treatment plan by adhering to all of your work restrictions and showing up for all of your physician ordered follow up appointments, you will demonstrate to your supervisor and to the Workers Compensation Commission that you genuinely want to restore your body to the highest level of wellness possible. 9. Time Off For Follow up Appointments If follow up appointments are ordered for you by your physician, you will be required to use your accrued leave (sick, vacation or compensatory time) once you return to work, if you appointments are scheduled during working hours. Sometimes you can schedule follow up appointments during non working hours, so you would not be required to use accrued leave time under these circumstances. 10. Temporary Income Benefits (TIBS) 70% of Your Salary If you do miss time from work because of a work related injury or illness, Workers Compensation Insurance will begin paying Temporary Income Benefits (TIBS) to you on the 8th calendar day you are off from work if your claim has been determined to be compensable, and you either elected to take the time off without pay or you had no accrued time available. Although there is a seven day waiting period where TIBS are not payable, should disability extend to the 14th day after the first day of disability, the carrier will then issue a TIBS payment for the waiting period. TIBS are calculated at approximately 70% of the amount of money you earned during the 12 weeks prior to your work related injury or illness. (*) TIBS can be paid to you only if you are on unpaid status during your time off from work. You cannot take accrued leave and receive TIBS at the same time.
6 11. UTD Benefits & Family Medical Leave If you do begin to lose time from work, your UTD health insurance, longevity accrual, and retirement account may be affected. You are advised to contact Human Resources at to find out whether your situation will impact these areas. Human Resources can also give you information about whether or not you are eligible for Family Medical Leave which, if you are eligible, would run concurrently with any work related lost time you take. 12. Modified Duty If your physician orders work restrictions for you that will require your department to make accommodations for you for a limited amount of time, you may be offered the opportunity to accept or decline a Modified Duty Work Assignment within your department. If your department is able to offer you a Modified Duty Work assignment, you will need to sign a Modified Duty Work Agreement (exhibit D14 in the UTD Administrative Policies and Procedures handbook) that will be designed for you by the WC Claims Analyst at UTD indicating that you either accept or reject this agreement. The Agreement will be based on your physician s work restriction orders. For more information about Modified Duty Work Assignment please refer to UTD Return to Work Policy on page D of the Administrative Policies and Procedures Manual:
7 13. Host Department Work Assignment If your supervisor determines that your department is unable to modify your job duties in order to accommodate your physician ordered work restrictions, you may be able to work in a Host Department on the UTD campus for a limited amount of time. The WC Claims Analyst at UTD will try to negotiate a Modified Duty Work Assignment in a Host Department for you. Your work restrictions, your skills and abilities will all be taken into consideration when trying to place you in a Host Department. If a temporary assignment is found for you, you will be required to sign a Modified Duty Work Assignment Agreement indicating you either accept or reject this work opportunity. 14. Return To Work Your Modified Duty Work or Work Assignment Agreement will be considered null and void on the day you are released by your physician to return to work without restrictions. When you are released from your work restrictions by your physician, you will be able to resume your regular job duties, if you have been released prior to the maximum limit of your agreement. It is important that you present your regular supervisor with a copy of the Work Status Report from your physician that reflects that you are able to return to full duty before your supervisor can allow you to return to your regular job.
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