Workers' Compensation

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1 Workers' Compensation Accident Reporting Procedures LISD FORMS AVAILABLE AT THE SAFETY WEBSITE ARE IN BOLD LETTERS 1. Employee reports accident or near miss to campus/department Safety Officer. The Safety Officer is usually an administrator such as an Asst. Principal. 2. Safety Officer fills out Supervisor's Incident report (first injury report) using descriptors such as all body parts (left & right) affected. NOTE: District Nurses are no longer required to assess or administer First Aid to employees as part of their job description. 3. Consent for Medical Authorization for medical records and reports are signed by injured employee. 4. Local Laredo, Texas Workers' Compensation Approved Doctors List is provided to employee a more current list is available on the Texas Worker's Compensation web site: 5. Safety Officer provides employee with a copy of the Supervisor's Incident report (first injury report). Employee seeking medical attention takes copy to an approved workers' compensation doctor or to Minor/ ER clinic that accepts workers' compensation insurance. 6. Employee follows up with Safety Officer and employee fills out Statement of Injured report. Special attention is given to: Witness Statements, Corrective Actions and Safety Violations if any are noted. Safety violations may involve the use of work orders and Personal Protective Equipment (PPE) as parts of Corrective Actions. All of the above mentioned reports should be faxed immediately to the LISD Workers Compensation office [ ] preferably no later than the end of the work shift. 7. Employees who miss work are required to access the district employee absence system. 8. Employees returning to work (RTW).from a work related injury must be cleared by the LISD Safety Dept/Workers Compensation Program, presently Ms. Juanita Lopez , fax Employees returning to work with limitations and /or light duty will be accommodated at their assigned campus/dept. u n l e s s HR and the Safety dept. deem otherwise. The employee will submit their RTW assignment to their work site supervisor/administrator. HR will notify the employee's former administrator/safety officer of any changes. 900 E. Lyon Laredo, TX Ph WK Fax E mail It is the policy of the Laredo Independent School District not to discriminate on the basis of race, color, national origin, gender, religion, limited English proficiency, or handicapping condition in its programs.

2 Laredo Independent School District Workers Compensation EMPLOYEE RETURNING TO WORK PROCEDURE 1. Employee receives Information Packet at time of claim/report of injury 2. Employee receives Doctor s Release and Functional Assessment Or DWC Employee Reports to Safety & Occupational Health Department with the Workers Compensation Clerk 4. Employee is issued Request for Authorization to Return to Work from Workers Compensation Clerk 5. Employee Reports to Human Resources Department with all documents 6. If approved to return to work by Human Resources, the Authorization form is signed & authorized 7. Employee Reports to his/her Job Site with a copy of the Approved Authorization Form 8. If Not approved to return to work, Human Resources will Document reason for Decline 9. Employee will be informed of denial, receive copy of Documentation & Instructed on Necessary Action or Process from Employee and/or District/ Human Resources 10. Copy of Completed Request for Authorization to Return to Work Form must be sent to Workers Compensation Clerk from Human Resources Revised

3 . Office tjseoitly Clana#: TEXAS SCHOOLS COOPERATIVE Medical Billing: J I Companies Fax: (512) Boyer Boulevard Suite 100 Toll Free Number: , Austin, TX WORKERS' COMPENSATION MEDICAL AUTHORIZATION FORM TO WHOM IT MAY CONCERN: I hereby authorize you to furnish to any and all information you may have concerning Name of Company Injured Employee or its representative, with respect to any illness or injury, medical history, consultation, prescriptions or treatment, including z-ray plates, and copies of all hospital or medical records. This applies to medical records while on active or reserve duty with any branch of the United States Military and Naturalization records included. A photostatic copy of this authorization shall be considered as effective and valid as the original. Signed: Address: Date:

4 1 NAME STATEMENT OF INJURED ADDRESS PHONE NUMBER SOCIAL SECURITY NO. DATE OF BIRTH PLACE OF BIRTH MARRIED / SINGLE NO. OF DEPENDENTS HEIGHT WEIGHT COLOR OF HAIR COLOR OF EYES ANY PREVIOUS HEALTH COND1TIONS1? DESCRIBE ALL PREVIOUS HEALTH CONDITIONS AND/OR PHYSICAL DISABILITIES, IF ANY. U YES LJ NO ANY PHYSICAL DISABILITIES? D YES U NO JOB TITLE HOURS PER DAY DAYS PER WEEK NAME OF YOUR SUPERVISOR DESCRIBE YOUR JOB DATE OF ALLEGED ACCIDENT PLACE OF ALLEGED ACCIDENT DATE OF HIRE AVERAGE WEEKLY WAGE $ TIME HOW DID THE ALLEGED ACCIDENT HAPPEN (BE SPECIFIC)? NAMES AND ADDRESSES OF WITNESSES, IF ANY DESCRIBE YOUR INJURY IN DETAIL ; DID YOU EVER INJURE THIS PART OF YOUR BODY BEFORE? IF SO, WHEN AND WHERE? D YES D NO ATTENDING PHYSICIAN ADDRESS PHONE NUMBER DATE OF FIRST VISIT NUMBER OF VISITS IF STILL RECEIVING TREATMENT, HOW OFI'KN DO YOU VISIT PHYSICIAN? WERE YOU HOSPITALIZED AS A RESULT OF THE ALLEGED INJURY? NAME OF HOSPITAL ADDRESS D YES D NO ADMISSION DATE DISCHARGE DATE WERE YOU COMPELLED TO STOP WORK BECAUSE OF THE INJURY? D YES D NO HAVE YOU RETURNED TO WORK? DATE OF RETURN LAST DAY WORKED AT WHAT WAGES? AT WHAT JOB? HOUR AM. P.M. AT WHAT JOB TITLE? D YES D NO I herebv request and authorize vou to furnish to or its representative, any and all information vou mav have concerning (Name of Company) (Enter Your Name) with respect to any illness or injury, medical history, consultation, prescriptions or treatment, including x-ray plates, and copies of all hospital or medical records. Armed Service Medical rooorda and HaturaliEation records infoiiripri A pvintnstatic ptiotnstatic copy of this authorization! shall be considered as effective and valid Sis the original. Signed: Date: 20 Address:

5 -;.. Office Use Only Claimfc :. -.. SUPERVISOR'S INCIDENT REPORT Full Name of Employee Involved/Injured: Date of Alleged Incident: / / Time of Alleged Incident: AM/PM Date Reported to Supervisor: / /. Lost Time: Yes No First Day Lost Time: / /. Return to Work: Yes No Date of Return to Work: / / Exact Location: Department: Job Title: Job Site: Date of Hire: Supervisor: Supervisor's Phone Number: Was this accident preventable? Yes No How could the supervisor help prevent this accident? Was Physician Contact Necessary? Yes If yes, Date of Notification: / / Time: AM/PM Physician Name: No Phone: Incident Facts; (Describe as accurately as possible what happened (i.e., if an injury resulted, state part of body injured and nature of injury). Were there witnesses? Yes If yes, list below. Name: Department: Job Title: No Final Disposition: Include Description of Action Taken. Name: Department: Job Title: Date Signature of Supervisor Reporting

6 v : v,..-. V.OfBceUse.Qnly Claim #r''-"--. j-"'.-" -V- ---^U^- WITNESS STATEMENT Witness Name: Age Phone #_ Witness Complete Address: Witness Employer Name, Address & Phone: If I should move or change my address, I can be located through: Who resides at: Name of injured employee:.... _ Date of Accident: _ ^ 200 Time of Accident: _ Place where accident occurred: _ Room _ Hall Cafeteria Other Location: Please explain fully what you know about this accident: Did you actually see this accident happen? If not, how did you learn about it? Describe Injury (part of body affected): Did this employee ever talk to you about getting hurt on the job? If so, how soon after the accident did this conversation take place? Do you know of any other injury, accident or illness that this employee has had? If so, explain: Has this employee worked since the alleged date of accident? _ If so, did he appear able to work as hard as before the accident? If not, explain: How long have you known this employee? Are you related to this employee? If so, what is your relationship? Please give the name and addresses of any other persons who might know anything about this accident: a. b. c. d. Witness Signature: Date: (USE OTHER SIDE IF MORE SPACE IS NEEDED) RETURN THIS FORM TO SUPERVISOR WITHIN 24 HOURS OF THE ACCIDENT. COPIES TO: CORPORATE OFFICE & ICON BENEFIT ADMINISTRATORS H, L.P.

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