` POLICIES AND PROCEDURES MANAGER/SUPERVISOR MANUAL WORKERS COMPENSATION INSTRUCTIONS FOR EMPLOYEES TO: FROM: SUBJECT: MANCON Supervisor MANCON Corporate Human Resources Workplace Accident, Injury and Illness Instructions DATE: December 2012 (Updated October 2013) When an employee reports an accident (car, forklift etc), injury (laceration, contusion, etc), or an illness (allergic reaction, exposure, etc) follow the steps below. Reporting an Accident, Injury, and/or illness Provide the employee the Employee Workers Compensation Packet and corresponding Physician Panel. For those managers with Quest Diagnostics Drug Screen set-up access, the manager needs to set-up the drug screen. For all others, contact MANCON Human Resources to set up the Drug Screen. The following items must be collected from the employee and returned to MANCON Human Resources. 1. Incident Report Incident report needs to be completed and signed by both the employee and the manager/supervisor. At the very least, return Page 2 of the packet to MANCON HR within 24 hours of notification of the incident. 2. Physician Panel This form is used to inform the employee of their options for medical treatment if desired. This form also provides the employee the location information for the drug screen site (if required). 3. Physician Note Form This form, three pages, is for the employee to take with him/her to the medical facility chosen. The treating doctor can complete this form identifying the results of his evaluation or he can submit a physician note on his letterhead regarding the results of his evaluation. 4. Quest Diagnostics Drug Screen Most work-related incidents require a drug screen. Site Offices can set up the Drug Screen through their Logins. Managers with Chain of Custody Forms and/or Drug Screen Kits, can give the form/kit to the employee and visit the Drug Screen site on the applicable Physician Panel. All others must contact MANCON HR for further instructions and forms. The employee must take a government issued ID ex. Driver s License to the drug screen location to obtain the drug screen. MANCON requires drug screens to be performed within 72 hours. 5. Authorization Form This form provides the medical facility, where the employee may seek treatment, the information they need for workers comp claims. Most importantly, this form instructs the facility to send MANCON the bills for related medical treatment. 6. State Workers Comp Form The following states require MANCON to provide the employee a state specific workers comp form for completion: AK, AR, CA, KS, MD, ND, OH, TX, WashDC, and WY. If the state where the incident occurred has this requirement, provide the form to the employee to complete. 7. Timesheet Entry Form The employee completes this based on the date/times s/he went for medical attention and/or a drug screen.
Completion of the Timesheet The approving manager is responsible to ensure that the timesheet accurately reflects the actual hours worked for any days associated with the date of the accident, injury, illness; the date when medical attention was sought, the date when the drug screen was performed, and the date when any follow up medical treatment is sought. Missed Time MANCON pays employees up to 8 hours on the day of injury for seeking medical treatment due to a work related injury. If the employee chooses not to seek medical treatment on the day of injury, MANCON will not pay him/her for missed time for seeking treatment on any day after the injury. Applicable MANCON Leave Policy guidelines will be enforced unless restricted by state regulations. MANCON pays employees for the time it takes to obtain a drug screen. (MANCON requires a drug screen be performed within 72 hours. Failure to adhere to these requirements will result in actions according to MANCON s Drug-Free Workplace policy signed upon hire.) Follow-up Appointments Employees are encouraged to make follow-up appointments before or after work or on the weekends to avoid missing time from work. If an employee misses time during their work schedule, MANCON will force an employee to use paid leave unless restricted by state regulations. Contact MANCON HR for further information. Physician Orders to Refrain from Work MANCON does not pay employees for missed time from work due to physician orders. Liberty Mutual, MANCON s workers compensation insurance company, may pay disability benefits for missed time due to physician orders based on the applicable state workers compensation regulations. If the employee asks you questions regarding applicable state regulations, instruct the employee to contact the Liberty Mutual representative assigned to the claim (the employee received a letter from Liberty Mutual with the contact information). Most states have a waiting period for disability benefits; therefore, when employees are ordered by a physician to refrain from work, employees are not forced to use paid leave during the waiting period, but are provided the opportunity to use paid leave if desired. Medical Bills Even if bills are presumed to be paid by MANCON or Liberty Mutual, the employee should not be receiving bills at their residence. All bills received regarding incidents related to MANCON must be forwarded to the MANCON manager or MANCON Site Office as soon as possible. The Manager/Site Office must forward the bills to MANCON HR.
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 ext 312 SUPERVISOR/MANAGER INCIDENT REPORT CHECKLIST MANCON Managers and Supervisors, The following Checklist and Incident Forms are provided by MANCON for use in all Auto Accidents, Building/Facility Damage, Injuries, Equipment Damage, and Public Property/Injury claims. When an incident occurs, complete the applicable pages for the incidents that have occurred. Page 1 for General Incident Information Page 2 for MANCON Automobile Damage Page 3 for Other Automobile Damage Page 4 for Injuries claimed Page 5 for Equipment and/or Property Damage Page 6 for Witness Statements Page 7-9 Send the Medical Report with the MANCON employee for initial medical treatment documentation from the medical provider for injuries claimed Page 10 for MANCON employee release for medical information regarding injuries treated Page 11Drug Screen Panel and Medical Facility identification Form Medical Treatment Authorization Form Original to Employee, Copy for HR Please check all forms sent to MANCON Corporate regarding this incident. If not all forms are available within 24 hours of the incident, Page 1 General Incident Information is required with a phone call or email with as much information as is available at the time. When an incident occurs, the following steps must be completed in addition to the applicable incident reports above. Assess automobiles, equipment, property and people involved. If immediate/life or limb threatening medical attention is needed, call 911 Obtain a statement from the MANCON employees involved Obtain copies of police report info and citations if given Complete the MANCON Physician / Drug Screen Panel identifying whether or not MANCON employees are claiming injuries and the location of medical attention if applicable. Send MANCON employees for a Drug Screen at the site identified on the Drug Screen Panel and obtain a Copy of the Chain of Custody Form confirming completion. This report and the attachments will serve as the record from which the online claim will be created and submitted. If you have questions regarding these steps, please contact: For Automobile/Equipment/Property Damage Fleet Manager Tony Schneider 757-460-6308 or 888-892-0787 ext 525 For Injuries Human Resources Laura Sipes 757-460-6308 or 888-892-0787 ext 312 FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM
POLICIES AND PROCEDURES MANAGER/SUPERVISOR MANUAL INCIDENTS Completing the Incident Form COMPLETING THE INCIDENT FORM MANCON strives to provide a safe and healthy workplace for all our employees. MANCON, with the help of its employees, strives to prevent incidents: accidents, illnesses, or injuries. MANCON maintains insurance for a variety of situations that can happen in the workplace or as a result of work performed on behalf of MANCON. Workers Compensation is an insurance program to provide medical care and other compensation to employees who are injured in the workplace while on the job. States have Workers Compensation laws that govern these programs in each individual state. RESPONSIBILITIES OF MANCON MANAGERS AND SUPERVISORS All incidents that occur in the workplace, in a MANCON automobile, or in the performance of work on behalf of MANCON must be reported to managers/supervisors immediately or as soon as possible, but not more than 24 hours after the incident. If unknown whether or not the incident occurred as a result of the worksite, report the incident anyways. Even if an injured employee feels ok and does not need medical attention, the incident must be reported. Managers/Supervisors must treat all incidents as serious and factual. If an employee approaches a manager or supervisor with information regarding an incident, the manager/supervisor must respond as directed on Page 1 of the Incident Report. If an employee is seriously injured, i.e. life or limb threatening, the Injured Employee should be taken to the nearest hospital for treatment or call 911. INCIDENT FORMS SUPERVISOR S REPORT OF INCIDENT/INCIDENT (Page 2) Site Managers/Supervisors are responsible for completing the Report of Incident/Incident Form as soon as possible and within 24 hours of notification. Date: The first date at the top of the form is the date the Report of Incident/ Incident Form is being completed. Involved MANCON Employee s Name and ID#: The name of the MANCON Employee involved in the incident. If more then one employee is injured, please complete a separate Report of Incident form for each MANCON Employee. Enter the Employee s MANCON ID#. Assigned Work Location: This is the location of the project and work site, i.e. NAS Corpus Christi, where the employee is assigned to work. Type of Work: Mark the box next to the work the employee performs in his/her job. If unsure about the category, enter the Employee s Job Title in the Other Category. Type of Incident: Mark the box(es) next to all applicable types of incidents. If unsure, enter a short reference in the Other Category. Incident Details: 1. Date of Incident: Enter the date the incident occurred. Time Injury Occurred: Enter the time the incident occurred. If unknown, approximate the time.
Time Work Shift Started: Enter the time the work shift started for this employee on the day of injury. Date Reported: Enter the date the incident was reported to the manager or supervisor. 2. Incident Physical Location: Enter the location/site within (or outside) the worksite where the incident occurred. Examples include: Stairwell between 3 rd and 4 th Floors, Building 123 Loading Dock, Corner of 5 th and Maple, etc including the City and State. Details Regarding the Incident at the Site: Enter all information pertaining to the location where the incident occurred. Examples include: ice on the road, ruptured fire hydrant, sun blocking visibility, etc. 3. Description of Incident: Enter information regarding the factual details of the incident. Be sure to include the type of work the employee was performing when the incident occurred, names of witnesses who may have seen what happened, anything potentially related to the incident etc. 4. Automobiles Damaged: Provide an overview of the automobiles involved (if applicable) and the damage sustained. Pages 3 and 4 will provide the opportunity to include more detailed information regarding damaged automobiles. 5. Injury Sustained: Provide an overview of the injuries sustained (if applicable) during or as a result of the incident. Page 5 provides the opportunity to include more detailed information regarding injuries, medical attention, etc. 6. Equipment Damage: Provide an overview of the equipment involved/damaged (if applicable). Page 6 provides the opportunity to include more detailed information regarding all equipment damaged. 7. Property Damage: Provide an overview of the property involved/damaged (if applicable). Page 6 provides the opportunity to include more detailed information regarding all property damaged. 8. Cause of the Incident: Provide the hazard information from the site of the incident that may have caused the injury/incident to occur; i.e. exposed razor, unlocked machine, etc. 9. Supervisors Name/Contact Information: Enter the name of the supervisor assigned to monitor the Injured Employee s work Job/task. 10. Describe Possible Causes for the Incident: Provide additional information available regarding other possible causes for the incident. 11. Describe Physical Evidence: Provide information regarding anything broken, out of place, etc regarding the scene of the incident, even if it doesn t seem relevant. 12. Date/Time Incident Called into Corporate: Initial and enter the date and time the initial incident information was provided to Corporate. If this occurred via email, provide a copy of the email notification to Corporate. The signature of the Supervisor completing the form needs to be included in the initial 24 hour notice to the Corporate Office. The signature from the MANCON Employee involved is required but can be provided within a reasonable time from the incident date. AUTOMOBILE ACCIDENT FORM Pages 3 and 4 MANCON automobile damage must be reported on Page 3. Basic information regarding where the automobile is assigned, the location of automobile after the accident, the list of passengers, damage to the automobile and information regarding what happened. Non-MANCON automobile damage must be reported on Page 4. If a MANCON employee is driving a non-mancon vehicle for MANCON business, the employee needs to complete this form. This form can also be completed for other vehicles involved in the incident. Basic information regarding the owner of the automobile, applicable insurance on the automobile, the list of passengers, damage to the automobile and information regarding what happened.
INJURY INFORMATION Page 5 Provide detailed information regarding the injuries sustained. Provide information regarding whether or not the employee left work for medical attention and whether or not the employee came back to work. In addition, make notes on the pictures of the front and back side of a body to show exactly where the pain, cut, etc occurred. EQUIPMENT AND/OR PROPERTY DAMAGE Page 6 Provide information regarding the owner of the equipment and/or property. Include information regarding the owner s insurance company. Be sure to include copies of police reports if applicable. Space is provided to draw a picture of the damage and any additional information. Attach pictures of the damage if possible. MANCON INCIDENT WITNESS STATEMENT Page 7 The following form must be completed by the witness. Managers and supervisors do not need to question whether or not the witness actually saw or heard anything regarding the incident. Managers and supervisors should simply collect the information from staff that have something to say about the incident. The validity of the witness statements will be determined by our insurance company. Date/Time of Incident: The date and time the incident occurred in the witness opinion. Date/Time of Report: The date and time the witness is providing the information regarding the incident. Witness Name: Name of the witness providing the information. Phone: Phone number for the witness where they can be contacted during normal business hours. Address: Address of the witness. This information may be used if our insurance company needs to get clarification of the details of the incident. Employed By: The name of the company the witness works for. This may or may not be MANCON. If concerns for documentation from a non-mancon employee, the witness information can be gathered by the manager/supervisor during the investigation and documented as a verbal conversation. Job Title: The job title of the witness. Department: The department the witness works in. Description of the Incident: The witness should describe in as much detail as possible, the incident that occurred, what happened, what may have caused the incident, etc. Brief Description of Witness Activity During Incident: The witness should describe his/her job or task leading up to and during the incident/incident. Witness Statement Describing Incident in Detail: The witness should describe the events leading up to and including the incident/incident from his/her perspective. Signature: Make sure the witness signs the form indicating that the information being provided is true and accurate to the best of his/her knowledge. RETURN TO WORK/ABILITY TO WORK RECOMMENDATION Pages 8-10 These pages should be given to an Injured Employee to take with them to the medical facility where s/he is seeking medical attention. The medical provider treating the Injured Employee should complete this form and give back to the Injured Employee. The Injured Employee should in turn fax the completed document to MANCON Corporate Workers Comp. If the medical provider declines to complete the Return to Work/Ability to Work Recommendation, the Injured Employee must obtain a physician s note identifying his/her return to work status.
PATIENT AUTHORIZATION TO RELEASE INFORMATION Page 8 This page simply needs a signature from the Injured Employee to authorize the medical provider/facility to release information regarding the treatment of the Workers Comp injury to MANCON or a MANCON Representative. WORKERS COMPENSATION AUTHORIZATION FORM Page 12 The MANCON Workers Compensation Authorization Form is for use with Workers Comp injuries. When an Injured Employee alerts his/her supervisor to a workplace injury, the Injured Employee is given the Authorization Form to take with him/her to the medical provider/facility visits. This form provides information regarding the injury and the services authorized by MANCON for medical treatment to the medical facility providing treatment. This form should only be used when a Workers Comp injury occurs. The manager/supervisor must sign the Authorization Form and make a copy prior to giving the Injured Employee the original Authorization Form. The copy must accompany the Incident Report sent to MANCON Corporate. TIMESHEET ENTRY FORM The Timesheet Entry Form is used to collect information from the employee regarding the time missed on the date of injury for medical attention and/or a drug screen and the time missed after the date of injury for a drug screen. Use this form to help make sure the employee only enters the actual hours worked on the date of injury and drug screen date. MANCON HR will use this form to identify what hours need to be added to the employee s timesheet under Workers Compensation. PROGRESSIVE MEDICAL FIRST FILL PRESCRIPTION CARD The Progressive Medical First Fill Prescription Card is for employee use for the first prescription they need filled for a work-related injury. This card is applicable under Liberty Mutual s Workers Compensation program and only valid for the first prescription. PHYSICIAN PANEL The Physician/Drug Screen Panel identifies approved/authorized medical providers/facilities and drug screen locations in the surrounding worksite areas. Please emphasize to the employee that each state has different requirements regarding medical treatment and that the employee needs to follow the instructions on the top of the panel. Some states require MANCON to choose the facility and others require that the employee can choose from any facilities in the state. The Injured Employee must be presented with this form to review after an injury is reported. If the Injured Employee wants to seek medical attention for his/her injury/illness, the Injured Employee must indicate, by circling, which medical facility s/he would like to go to. A copy of the completed Physician Panel must be kept with the Incident Report to send to Corporate. The original Physician Panel must be given to the Injured Employee to take with him/her to the chosen medical facility. If the Injured Employee tries to seek medical attention from one facility but is redirected to another facility, the Injured Employee must notify MANCON Corporate immediately following the medical visit. If the injury/illness is life or limb threatening, instruct the employee to seek immediate medical attention from the nearest medical facility or by calling 911. If an Injured Employee declines to seek medical treatment initially, but decides later (outside of normal work hours) to seek medical attention, the Injured Employee can use the Physician Panel to identify which provider/facility to seek medical treatment from.
THE FOLLOWING WORKDAY The Manager needs to follow up with MANCON HR to review the paperwork received and next steps regarding the claim.
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 REPORT OF INCIDENT Date: Assigned Work Location: Involved MANCON Employee s Name and ID#: Type of Work: Type of Accident (Check all that apply): Administrative Automobile Accident (send to Fleet Mgr) Professional Building or Facilities (send to Fleet Mgr) Management Employee Personal Injury (send to HR) Technical Equipment Damage (send to Fleet Mgr) Maintenance Public (Property or Personal) Injury (send to Fleet Mgr) Other Other (send to both HR and Fleet Mgr) ACCIDENT DETAILS: 1. Date of Incident: Time Incident Occurred: Time Work Shift Started: Date Reported: 2. Incident Physical Address: Details regarding the incident at the site: 3. Description of Incident (Include all details: what happened, who was doing what at the time of the incident, what safety equipment is required for the task, what safety equipment was used for the task, what possibly caused the accident, etc. Attach additional pages as needed): 4. Automobiles Damaged (complete then proceed to Page 3-4): 5. Injury Sustained (complete then proceed to Page 5): 6. Equipment Involved/Damaged (complete then proceed to Page 6): 7. Property Involved/Damage (complete then proceed to Page 6): 8. Cause of Accident (Be Specific): 9. Supervisor s Name/Contact information: 10. Describe possible causes for incident: 11. Describe Physical Evidence at Scene of the Incident (Dropped boxes, Broke equipment, etc.): 11. Initial and provide Date/Time the Incident was called into MANCON Corporate. Human Resources? Date/Time Called In: Fleet Manager? Date/Time Called In: Employee s Signature: Human Resources Signature/Date notified: Site Supervisor s Signature: Date Received: FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 1 of 11 Revised 10/2013
Fleet Manager Signature/Date notified: Date Received: AUTOMOBILE ACCIDENT REPORT Make copies for completion for each MANCON person/vehicle involved. Send this form to Fleet Manager with other reports. MANCON Driver: DOB: Male/Female: MANCON Driver License information: Phone: MANCON Driver Address: MANCON Location and Name Vehicle is assigned to: Purpose for use of Vehicle: Year: Make: Model: VIN: Vehicle License Plate: Location of MANCON Vehicle after Accident: Estimated Cost of Repairs: Vehicle Garaged at: 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 Passenger 1 in MANCON Vehicle: Passenger Address: Passenger 2 in MANCON Vehicle: Passenger Address: Passenger 3 in MANCON Vehicle: Passenger Address: Phone: Phone: Phone: Using the diagrams and lines below, draw and describe the accident and damage to MANCON Vehicle. FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 2 of 11 Revised 10/2013
AUTOMOBILE ACCIDENT REPORT Make copies for completion for each NON-MANCON person/vehicle involved. Send this form to Fleet Manager with other reports. Name of the Other Driver: Phone: Other Driver License information: Address: Insurance Company: Phone: Insurance Address: Owner of Other Vehicle: License Plate: Year: Make: Model: Other Identifying Features: Estimated Cost of Repairs: 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 Passenger 1 in MANCON Vehicle: Passenger Address: Passenger 2 in MANCON Vehicle: Passenger Address: Passenger 3 in MANCON Vehicle: Passenger Address: Phone: Phone: Phone: If the Police were contacted, provide the officer s name and report number (also attach a copy of the accident report filed). Using the diagrams and lines below, draw and describe the accident and damage to other Vehicle. FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 3 of 11 Revised 10/2013
INJURY INFORMATION Make copies for completion for each person injured. Send this form to Human Resources with other reports. Injured Name: Phone Address Job Title Department Date of Birth: Female/Male 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 First Aid Provided on Site? If Transported Off-Site, How? Employee (Choose one): Remained at work Returned to Work at Did not return to work Employer/Contact Name/Phone (if not MANCON) Employer Address and Phone: FRONT SIDE BACK SIDE Indicate the area(s) injured using the graphics above for the front and back side. Description lines are provided for your convenience. FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 4 of 11 Revised 10/2013
Owner of Equipment or Property: Address of Owner: Contact Name/Phone: 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 EQUIPMENT AND/OR PROPERTY DAMAGE Make copies for completion for each piece of equipment and/or property damaged. Send this page to Fleet Manager with the other reports. Insurance Company: Insurance Address: Phone: Estimated Cost of Repairs: If the Police were contacted, provide the officer s name and report number (also attach a copy of the accident report filed). Using the boxes above, drawn the incident/damage occurred. Description lines are provided below for a detailed description of the incident and the damage that occurred. Attach photos or other documentation of the damaged equipment/property. EQUIPMENT DAMAGE PROPERTY DAMAGE FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 5 of 11 Revised 10/2013
INCIDENT WITNESS STATEMENT 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 Date/Time of Incident Date/Time of Report Witness Name Phone Address Employed By Address Job Title Department Description of Incident Brief Description of Witness Activity During Incident Witness Statement Describing Incident in Detail (Including Names of All Person Involved): I have read the above and it is true to the best of my knowledge: Signature Printed Name Date Time FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 6 of 11 Revised 10/2013
RETURN TO WORK / ABILITY TO WORK RECOMMENDATION If injuries claimed by MANCON employees, please send this three page form with the employee to the medical facility providing treatment. 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 Patient s Name: Social Security Number: TO BE COMPLETED BY TREATING/ATTENDING PHYSICIAN Brief Diagnosis / Condition: I saw and/or treated this patient on medical problem: and based on the above description of the Patient s current Recommend his/her Return to Work with No Limitations on (date) Patient may Return on (date) with a Daily Time Limitation of hours and/or Limitations specified hereinafter: 1. In an 8 hour work day, Patient may: PHYSICAL LIMITATIONS A. Stand/Walk B. Sit C. Drive D. Use Hands Repetitively E. Use Feet Repetitively F. Bend/Stoop G. Twist H. Squat/Kneel I. Climb Steps/Ladders J. Reach/Stretch Not At All Occasionally Frequently FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 7 of 11 Revised 10/2013
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 2. In an 8 hour work day, Patient may: ENVIRONMENTAL LIMITATIONS A. Temp. Above 100º F B. Temp. Below 20º F C. High Humidity D. Unventilated E. Poorly Lighted F. High Noise G. Overcrowded H. Tight Restricting Areas Not At All Occasionally Frequently ABILITY TO LIFT AND CARRY 3. Check the category most appropriate for the Patient s current condition: Sedentary Work Lift up to 10 pounds with occasional walking, standing, or carrying. Light Work Lift up to 20 pounds with frequent walking, standing and carrying objects up to 10 pounds. Medium Work Lift up to 30 pounds with frequency including walking, standing, and carrying same. Full Duty Work Extended lifting and moving of material up to 50 pounds. OTHER INSTRUCTIONS AND/OR LIMITATIONS 4. Respond as appropriate for the Patient s current condition: A. List currently prescribed medications including name, dosage, periodicity, etc. B. Is the Patient s diet a factor? If so, describe dietary requirements C. Could the Patient faint or otherwise lose consciousness at the workplace as the result of the current medical condition? D. Can the Patient s current condition cause significant risk to the health or safety of the Patient in the workplace? FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 8 of 11 Revised 10/2013
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 To others working with him/her? If so, How can this risk be mitigated? E. Does the Patient s current condition include any mental/emotional considerations which the employer should attempt to accommodate (Explain)? F. Additional Advice/Comments? DISPOSITION / ADVICE 5. Any restrictions or limitations herein are in effect until (date) or until the Patient is re-evaluated on (date). Patient is not able to Return to Work at this time Patient will be re-evaluated on (date). Patient is being referred to for purpose of I will will not remain as Patient s Primary Physician of Record. Medical Provider Name (Printed) Medical Provider Signature Date FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 9 of 11 Revised 10/2013
PATIENT AUTHORIZATION TO RELEASE INFORMATION 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 I HEREBY AUTHORIZE MY Attending Physician and/or hospital to release any information, or copies thereof, acquired in the course of my examination or treatment to my employer and/or his representative. Patient s Signature Date FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 10 of 11 Revised 10/2013
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone: (757) 457-9312 or (888)892-0787 MANCON DRUG SCREEN PANEL All on-the-job injuries or other accidents MUST be reported IMMEDIATELY to a MANCON SUPERVISOR or MANAGER and an accident report MUST be filled out. MANCON requires drug screens when injuries, illnesses, or incidents occur in or as a result of the workplace. The following Drug Screen Location is provided for your reference to obtain the screen. Drug Screen Location Site Name Site Full Address Site Phone Number Site Fax Number Site Contact Person Drug Screen Hours Medical Treatment Location If you received a Physician Panel in the packet of Workers Compensation Information, please review that panel for information regarding where you must seek treatment for this claim. If you did not receive a panel in your packet, you may choose your medical provider in accordance with the applicable state regulations. Site Name Site Full Address Site Phone Number Site Fax Number Site Contact Person Medical Attn Hours I have selected the above identified facility to administer medical treatment for my potential worker s compensation claim. I have chosen not to seek medical treatment for my workplace injury. I understand that if I feel the need to seek medical treatment for this incident at a later time, I may do so by visiting one of the above approved medical facilities. It is my responsibility to inform MANCON Corporate Worker s Comp at (757) 457-9312 if/when I seek medical treatment. I do not want to claim an injury at this time. Signature Date FORWARD COPY WITHIN 24 HOURS OF INCIDENT TO MANCON CORPORATE OFFICE HUMAN RESOURCES ATTN: LAURA SIPES FAX 757-457-9345 or EMAIL LSIPES@MANCONINC.COM FLEET MANAGER ATTN: TONY SCHNEIDER FAX 757-457-9354 or EMAIL TSCHNEIDER@MANCONINC.COM Page 11 of 11 Revised 10/2013
` POLICIES AND PROCEDURES MANAGER/SUPERVISOR MANUAL INCIDENTS W/C FAQs by Employees TO: FROM: SUBJECT: MANCON Managers/Supervisors MANCON Corporate Human Resources Workers Compensation Workers' Compensation Frequently Asked Questions DATE: November 17, 2008 (updated October 2013) Many people assist MANCON Corporate with the Workers' Comp program. Our employees tend to ask similar questions from our Site Offices regarding this program. Here are a few questions typical questions and MANCON answers. (Please note, Incident refers to any non-injury incident, injury, accident, etc.) FAQ1 FAQ2 FAQ3 A MANCON employee (or site supervisor) just called me to alert me to an incident at work. What do I do? If this is an injury or serious accident, send the employee to the nearest hospital or approved clinic for treatment. See the Liberty Mutual Physician Panel for list of approved Hospitals and Clinics. If there is no Liberty Mutual Physician Panel, the employee can seek treatment wherever they want. The following forms should be completed immediately but not later then 24 hours after the incident (or 24 hours after being notified): Page 1 of Incident Report, Drug Screen Panel, Authorization Form, and Witness Statements. Remember, each employee involved in the incident MUST have a DRUG SCREEN. The Drug Screen should be completed on the date of the incident but not later then 72 hours after the incident (or 72 hours after being notified). Also remember to send anything/everything related to the injury, follow-up, physician information, etc to MANCON Corporate Workers Comp for the files. None of this information should be kept at the Site Office. The employee went to the doctor, will s/he get paid for the time s/he missed work? Employees will be paid on the date of incident only, up to their normal work hours for that day, for the time it takes them to seek medical treatment and get a drug screen. Employees are not required to seek medical attention. It is the employee s decision regarding whether or not they seek initial and follow up treatment. Time missed for medical treatment on a day other then the date of incident will not be compensated by MANCON. An employee was involved in an accident at work, but is not injured, does this still need to be reported?
Yes. All incidents, accidents, injuries, etc must be reported whether or not an injury occurred. MANCON policy states that employees involved in incidents in the workplace or on work time must obtain a Drug Screen. The Drug Screen should be performed on the same day of the incident but not later then 72 hours after the incident. As a priority, Drug Screens should be performed at a Quest Diagnostic center or affiliated center. If none are available, contact MANCON HR. FAQ4 FAQ 5 FAQ5 FAQ6 FAQ7 How does the employee complete her/his timesheet for the Date of Incident? On the date of incident only, the employee must fill in the actual hours worked. It is the site office s responsibility to find out what time the employee left for the medical treatment and what time s/he returned. There is a form for this information in the Incident Report. Submit this information to MANCON HR for further processing: due at the end of the pay period. How does the employee complete her/his timesheet for the Date of the Drug Screen? On the date the Drug Screen occurs (even if after the date of incident) the employee should only fill in the actual hours they worked. Please make a note of the date, time out, and time back (or end) for obtaining the drug screen. There is a form for this information in the Incident Report. Submit this information to MANCON HR for further processing: due at the end of the pay period. The employee did not seek medical attention on the day of incident OR the employee did not report the incident the day it happened, but now s/he wants to see medical attention. Will the employee be paid for time away from work? No. MANCON only pays for medical attention on the Day of Incident. An employee can seek medical treatment after the incident occurs, if they feel it is necessary. Most clinics have hours after work and on weekends. If this occurs, notify MANCON HR, complete the process for reporting an incident as detailed in FAQ 1, including a drug screen. The physician notes state the employee is not cleared to return to work, but the employee feels fine and wants to return, can s/he? Yes, physicians can instruct employees to refrain from working after an incident. However, it is the employee s right to return to work if they wish but MANCON requires a physician note stating the employee can return with or without work restrictions. Submit both physician notes to MANCON Corporate HR. The physician notes gave the employee work restrictions, what happens now? When an employee has work restrictions and the site can accommodate those work restrictions, the employee can return to work with the modified duty. If the site cannot accommodate restrictions, the employee will be
placed on a Leave of Absence due to Workers Comp. Additional information can be obtained by contacting MANCON HR. FAQ8 FAQ9 The employee has been out of work for 3+ work days, will MANCON pay for the time missed? MANCON s Workers Compensation Insurance (Liberty Mutual) handles missed pay for employees due to a work-related incident. Instruct the employee to contact their Liberty Mutual assigned representative regarding specific state laws that apply. Do not answer these questions on your own because MANCON does not pay anything to the employee regarding missed days. If an employee is out for more than 3 days, complete the MANCON Leave of Absence Form and submit to MANCON HR. An employee needs to take time off work during the day for follow-up medical treatment due to a workers comp injury. How do I fill out the timesheet? Recall that MANCON only pays for medical treatment on the day of injury. MANCON encourages employees to schedule follow-up appointments before/after work or on weekends (most clinics can accommodate this). If not, the employee must record only the actual hours worked for the days when appointments occur and the employee may be forced to use paid leave available for missed time. Any questions that still remain should be forwarded to MANCON Corporate Human Resources 888-892-0787
POLICIES AND PROCEDURES MANAGER/SUPERVISOR MANUAL INCIDENTS Workers Comp RTW WORKERS COMPENSATION RETURN TO WORK GUIDELINES When an Injured Employee seeks medical treatment for an injury that happened at work or in the course of performing work for MANCON, the employee is given a physician s note confirming whether or not the employee can return to work and/or whether or not restrictions are required. MANCON strives to return employees to work, even if restrictions are required. However because most of our employees work at customer locations, MANCON cannot always provide restricted work. UNABLE TO RETURN TO WORK Some injuries affect an Injured Employee s ability to perform all parts of their job. Injured Employees are instructed not to return to their jobs until future assessments of their abilities are performed. When this occurs, an Injured Employee will remain away from work until the future assessments are completed. As soon as the Manager/Supervisor is aware of this status, the Manager/Supervisor must submit a MANCON Leave of Absence Form indicating the leave is due to Workers Compensation. An attached copy of the physician note is required. MANCON HR tracks the progress of Injured Employees during this time to ensure the Injured Employee returns to work as soon as their provider authorizes it. If an Injured Employee has physician orders to refrain from working but the Injured Employee wants to return to work, contact MANCON HR for instructions. In addition, if an Injured Employee is authorized by his/her physician to return to work but the Injured Employee refuses, contact MANCON HR for instructions. RESTRICTED WORK Some injuries affect an Injured Employee s ability to perform parts of their job or other restrictions. When this occurs, medical providers release the Injured Employee to return to work with restrictions. The medical provider identifies which parts of the Injured Employee s job the Injured Employee can perform. MANCON prefers to keep their staff working, even with restrictions. Examples of restricted or accommodating work include the following: temporarily restructured duties, shortened work hours, temporary transfers to other jobs/locations, etc. Once a work restriction is identified by the medical provider, MANCON HR will review the restrictions with the Manager/Supervisor. The Site Manager/Supervisor will determine if the restrictions can be accommodated at the job site or another site location. If the restrictions cannot be accommodated, the Injured Employee will not return to work until the site can accommodate work restrictions. (If restricted work is not available, follow the instructions for the Unable to Return to Work section above, including the Leave of Absence Form.) If the restrictions can be accommodated, the Injured Employee will return to work, working only those tasks that the medical provider has authorized. If this occurs, MANCON HR will provide a modified duty letter for the employee to sign and return confirming their acceptance of the modified work. If there are any questions regarding accommodating work restrictions, contact MANCON.
FULL DUTY WORK Some injuries or current assessments of past injuries authorize Injured Employees to return to work without restrictions. This means the Injured Employee may return to work and perform all normal functions of the position. This is the ideal Workers Comp status as this is the goal MANCON has for all Workers Comp injuries. If an employee previously received a modified duty letter due to work restrictions and has now been deemed able to work full duty, MANCON Corporate will provide a letter to the Manager/Supervisor offering the employee full duty work. MANCON Corporate requires completion of this offer letter. If Managers/Supervisors have questions regarding the return to work status for Injured Employees, contact MANCON HR at 888-892-0787.