Workers Compensation Program

1 Workers Compensation Program I. PURPOSE AND SCOPE The purpose of this document is to provide procedures for reporting on the job injuries and/or illnesses and obtaining treatment.

2 II. REFERENCES A. Replaces Workers Compensation Program procedure B. Florida Workers Compensation Law, F. S. Chapter 440 C. Workers Compensation and Property & Liability Policy D. Family Medical Leave Act (FMLA) III. APPLICABILITY This procedure applies to all City of the Riviera Beach employees covered by the City s Workers Compensation Program. (1) Scope and Purpose: (a) City of Riviera Beach (City) recognizes the inherent value of all its employees. As a result, the City is committed to the retention of our employees, even when injuries or illnesses intervene and threatens their ability to work productively. City has therefore, adopted a comprehensive Stay at Work Management Program to enable, whenever feasible, injured and/or ill employees to return to work as quickly and safely as possible after the onset of an injury or illness. The Stay at Work Management Program facilitates this return to work through close communication between employees, appropriate administrators, and the medical community. (2) Definitions (a) Restricted Duty/Modified Duty (/) Light Duty When an employee s physical capabilities are modified by the Worker s Compensation Authorized Treating Primary Care Physician (PCP) resulting from a workplace injury arising out of the course and scope of an injured worker s employment. Restricted/Modified duty is also known as light duty. (b) Lost Time When an employee is taken off of work by the Authorized Treating Primary Care Physician or when an assessment by the injured employee s supervisor, the Risk Manager and the Director of Human Resources concludes that the employee s work restrictions cannot currently be accommodated. (c) If the injured employee is not in need of outside medical treatment or refuses treatment, the supervisor will document the injury on the first report of injury or illness Report Only Refusal of Treatment Form (Attachment #1). This documentation protects the employee in the event that the employee desires to receive treatment at a later date. (d) If the injured employee requests medical treatment, the employee s supervisor will ensure that the injured worker is directed to receive appropriate medical treatment. The supervisor will process the required Notice of Injury and Request for Treatment Forms in accordance with the City s Accident Reporting Procedure. (e) Injured worker shall report to the City s medical treatment provider. Such treatment or continued treatment shall only be with the City s approved providers as may be authorized by the City s third party administrator.

3 (f) Injured worker with life-threatening injury may report to the nearest emergency facility or as authorized by the City. (g) Expenses for medical treatment are paid by the City or through its third party administrator who authorized treatment. Employees who fail to report an injury and does not receive authorization to seek medical treatment, will be subjected to paying the medical expense out of their pocket for medical treatment provided the treatment is without prior authorization. Employees seeking medical treatment from a medical provider not on the City s approved medical provider list will be responsible for that medical treatment. (3) Follow-up (a) The injured employee shall attend all scheduled medical appointments and related treatment. If an injured employee cannot attend an appointment, the employee shall notify the City s Risk Management Division or Third Party Administrator (TPA) and the medical provider at least 24 hours before the appointment. (b) Employees should schedule appointments outside of the employee s normal working hours. If this is not possible, the employee may attend the medical appointment during work hours in accordance with the City s policy. Only the actual time for the travel and the appointment will be allowed. The employee must return to work, if the workday has not ended, otherwise the employee may be subject to progressive discipline that may include termination. (c) Following any appointment for treatment of a workplace injury, the employee shall immediately contact the supervisor and provide current work status documentation (Physician Activity Status report provided by the medical provider). The supervisor will send the work status documentation to the Risk Management Division of Human Resources Department and maintain a copy in the departmental file. (4) Return To Work (a) Injured employees are returned to work on Restricted/Modified duty with specific restrictions. If an employee is returned to work, the supervisor will not assign duties that are beyond the employee s restrictions. If an injured employee willfully violates the work restrictions, the employee may be subject to progressive discipline that may include termination. (b) Restricted/Modified duty only relates to employees whose illness or injury was job related. (c) Managers and Supervisors shall evaluate the restrictions placed on the employee by treating physician and determine the ability of the employee to perform any needed work. If the supervisor feels that the employee s restrictions cannot be reasonably accommodated, they will contact Risk Management Division of the Human Resources Department. The Risk Management Division may schedule an assessment of the employee s work capabilities. 1. The injured employee s supervisor, the Risk Manager and the Director of Human Resources will conduct any necessary assessment. 2. Where the employee s work unit does not have a job to accommodate the employee s restrictions, a Department search will occur to determine if there is a job to accommodate the employee s medical restriction.

4 In the event an employee s Department cannot accommodate the employee s restrictions, then a City wide work search will be conducted to determine if any Department can accommodate the employee s medical restrictions. 3. If the assessment concludes that the employee s restrictions cannot be reasonably accommodated, they will inform the employee that pending further assessment of restrictions or if another position becomes available with the employee s restrictions; the employee will be at Lost Time status. (d) The restricted/modified duty program requires the participation of all injured employees who are released to perform Restricted/Modified duty work by the Authorized Treating Primary Care Physician. If an injured employee refuses to participate in the program, workers compensation benefits will cease, and the employee may be subject to progressive discipline that may include termination. (e) While on Restricted/modified duty, the injured employee may receive their normal hourly rate of pay and benefits. Scheduled hours of work may be reduced. (f) Restricted/ Modified duty is temporary and is not considered a permanent accommodation for a workplace injury. Note: (For Union employees please see your labor agreements) (g) Restricted Duty/ Modified Duty assignment may not extend beyond 120 days. When an employee has been in a Restricted/modified duty assignment for 120 days, an assessment will be made regarding the employee s work status. (h) When an employee has reached Maximum Medical Improvement (MMI) as determined by the Authorized Treating Primary Care Physician, an assessment may be made regarding the employee s ability to return to regular job duties. 1. The injured employee s Department Manager, Supervisor, Risk Manager and Human Resources Director may conduct the assessment. 2. If the assessment concludes that the employee cannot perform their essential duties with or without reasonable accommodation, posted jobs will be reviewed to determine the employee s ability to work in other positions. If the employee is qualified and meets the minimum physical requirements for a posted job, the employee will be considered for that job. If selected for the job, salary will be determined according to transfer guidelines. 3. If an employee refuses to accept an offered job, the employee may be terminated. 4. If a position is not available for the employee, the employee may be in a no work status as outlined in the labor agreement. (i) Assignment to any of the type of positions described in this policy will be documented in a bona fide offer of modified or transitional employment letter to the employee. The bona fide job offer of modified or transitional duty letter shall include the following information: (1) The type of position offered and the specific duties;

5 (2) A statement that the City is aware of and will abide by the physical limitations under which the treating physician has authorized the employee to return to work; (3) The maximum physical job requirements; (4) A statement that the City cannot guarantee that a position will be available should the employee fail to accept the assignment; and (5) The name of the person whom the employee can contact for answers to questions about the assignment, job modifications, or other relevant provisions. The employee may accept or reject the bona fide offer of employment. The employee should be informed that rejection of the bona fide offer of employment may jeopardize continued temporary income benefits. If the employee accepts the bona fide offer of employment, then the employee shall perform the duties of the position for the term of the assignment or until the employee is able to return to full duty, whichever is sooner. If the employee rejects the bona fide offer of employment, then the employee remains off-work according to the labor bargaining agreement.(see labor agreement Contract). If the employee is unable to return to full duty by the end of the assignment period and/or by the end of the time period outlined in the union contract, then the employee s continued employment with the City shall be considered based upon the business necessity of filling the employee s position. Nothing in this policy shall be construed as requiring the city to retain an employee who is not able to return to work following a workplace injury, and such decisions regarding continued employment will be the sole discretion of management with appropriate consideration and attention given to relevant laws, policies and/or labor agreements. (5) Lost Time (a) Injured employees in lost time status are to contact their supervisor a minimum of once a week (not including weekends and holidays), to update the supervisor on their condition. (b) Employees in lost time status are required to return all City s owned (equipment and vehicles to their supervisor) property. Failure to return all City owned property within one week of an employee reaching Lost Time status may result in termination.

6 (c) Once the employee has been released to return to work, the employee will notify their supervisor immediately. Failing to do so may subject the employee to progressive discipline that may include termination. (d) Lost time due to a workplace injury will count towards the employee s Family and Medical Leave Act of 1993 (FMLA) entitlement. Duration of Transitional Duty Assignments The duration of the transitional duty assignment will be determined on a case-by-case basis by the employee s department in consultation with the City s Risk Management Division of the Human Resources Department, but will not normally exceed one year. If it is determined that the employee has long-term restrictions that result in the inability to perform the essential functions of the regular position, the provisions of the Americans with Disabilities Act (ADA) and other applicable laws will be evaluated to determine suitability for employment. ADA Compliance The City of Riviera Beach complies with the Americans with Disabilities Act which prohibits discrimination against qualified individuals with disabilities. Nothing in this policy shall be used as the basis for illegal discrimination against any individual or group. FMLA Compliance The City of Riviera Beach complies with the Family and Medical Leave Act of 1993, and as amended. Should a work related injury or illness be covered by the FMLA, the City will apply the provisions of the appropriate policy. Workers Compensation/Return-To-Work Compliance It is a violation of the Return To Work Policy, procedures, and state and federal law to discharge or in any other manner discriminate against an employee because the employee: Files a Workers Compensation claim in good faith; Hires a lawyer to represent the employee s interest in a Workers Compensation claim; and/or institutes or causes to be instituted in good faith a proceeding with the State of Florida Statue. Workplace Safety The City will make every reasonable effort to investigate the cause of the occupational injury or illness to determine what actions can be taken to prevent a reoccurrence of the injury or illness. An

7 employee will not be placed into a transitional or regular position if such an assignment would place the employee or others in danger. Medical Expenses Charges for first aid treatment, hospital bills, prescription drugs, doctor s charges, etc., are covered provided the proper procedures are followed as outlined above for reporting the accident and treatment of the employee. Employee Options An employee has the following options on the use of Sick Leave or Annual Leave for absence due to a Workers Compensation claim: Use accrued sick or annual leave after the first seven (7) calendar days in order to be paid full salary, and then elect to receive Workers Compensation during the remaining period of injury-related absence, or Exhaust all accrued sick leave and annual leave (in that order) to supplement Workers Compensation pay, or Retain all accrued sick leave and annual leave, and after the seven (7) calendar days waiting period, receive Workers Compensation during the remainder of the injuryrelated absence. Note: If an employee seeks medical attention with an unauthorized physician and is absent from work during the first seven (7) days has no accrued sick or annual leave, the absence must be coded as Leave Without Pay (LWOP) IV. PROCEDURES During a Workers Compensation claim, it is important that the manager/supervisor, employee, Risk Management Division and the third party administrator communicate with one another to ensure that the City of Riviera Beach employee who has experienced an onthe-job injury or illness returns to their normal job duties as soon as possible. The Risk Management Division and Third Party Administrator (TPA) are available to answer questions or provide guidance concerning Workers Compensation procedures. A. Responsibilities

8 Employee - All City of Riviera Beach employees are required to immediately report on-the-job injuries and/or illnesses to their immediate supervisor. Note: Florida statue state all claims must be reported no later than thirty (30) days or your claim may be denied. (Reference: Section 440.185, Florida Statutes). 1. Management/Supervisory - Supervisors are responsible to ensure all necessary Workers Compensation reports are signed, completed, faxed or e-mailed when necessary information is collected and submitted as a complete packet to the Risk Management Division immediately following an incident. These reports include A. First Report of Injury or Illness Refusal of Treatment Attachment #1 B. City of Riviera Beach Supervisor accident/ incident report Attachment #2 C. Employee Statement Form- Attachment#3 D. Witness Statement Attachment #4 E. Risk Management Division Memo to Injured Employee- Attachment #5 F. City s Medical Authorization Atatchment#6 F. Fraud Statement- Attachment #9 2. Service Providers - The Third Party Administrator (TPA) will conduct investigations to gather information, obtain statements, and communicate with injured employees and their supervisor. The City s managed healthcare company s Case Manager along with the TPA will coordinate the Worker s Compensation medical care of employees. Employees should contact the Case Manager whenever they have questions about their Workers Compensation medical care. The Case Manager can be contacted seven (7)-days a week and for Catastrophic cases twenty four-hours a day, seven days a week. B. Emergency Medical Treatment 1. The employee (or employee witness) will notify the supervisor as soon as possible if the injury/illness requires emergency medical treatment and is considered lifethreatening. 2. In the event of life-threatening injuries or illnesses, someone should call 911 immediately. Employees with life-threatening injuries or illnesses should be transported to an urgent care facility/hospital by ambulance. If employee is unable to communicate with the urgent care facility/hospital due to medical condition, supervisor and/ or Risk Management will ensure all information is provided to the urgent care facility/hospital and the Third Party Administrator. If unsure whether a medical condition is a life-threatening emergency, 911 should be called. Examples of life-threatening injuries or illness include, but are not limited to: a. Unconsciousness b. Broken bones c. Sudden dizziness or difficulty seeing d. Severe abdominal pain e. Trauma or injury to the head f. Partial or total amputation of a limb or extremity g. Persistent pain or discomfort in the chest or arms

9 h. Not breathing or having trouble breathing i. No signs or lack of circulation j. Severe bleeding k. Seizures that are unusual, prolonged or multiple, last more than five (5) minutes, result in injury or occur in someone who is pregnant or diabetic l. Drug overdose m. Eye injuries n. Gunshot, knife or other weapons wound o. Accidents such as falls or involving motor vehicles p. High fever (greater than 101 F) with a severe headache and a stiff neck 3. The 911 caller should provide the following information to the 911 operator: a. The address and/or location of the emergency. b. The telephone number where the emergency is located. c. A brief description of the problem including whether the person(s) is conscious and/or breathing. d. The name of the employee calling 911. Once the 911 call has been made, the caller should remain on the line to respond to additional questions from the 911 operator, if necessary. 4. If possible, the supervisor will provide two (2) copies of a First Report of Injury or Illness to the employee and/or ambulance crew to present to the urgent care facility/hospital and pharmacy, if necessary. Questions regarding treatment or prescriptions should be directed to the third party administrator and/ or Risk Management. The employee's supervisor will ensure that all reports are forwarded to the Risk Management Division. 5. As soon as possible following the emergency treatment, the employee must report to the authorized Workers Compensation Healthcare Provider as required for continued Workers Compensation coverage. C. Non-emergency Medical Treatment 1. If the injury/illness does not require emergency medical treatment and the injury/illness is not considered life threatening, the employee will notify the supervisor immediately. (If unsure whether a medical condition is a life-threatening emergency, 911 should be called.) Examples of illnesses/injuries that may not be life-threatening include, but are not limited to: a. Rashes

10 b. Upper respiratory infections c. Sore throats d. Earaches e. Headaches f. Abrasions g. Lacerations h. Flu like symptoms i. Back pain j. Sprains k. Minor fractures 2. The supervisor will provide two (2) copies of the First Report of Injury or illness to the employee to present to the healthcare provider and pharmacy, if needed. The employee must provide the healthcare provider with a copy of the medical authorization form. 3. Questions regarding medical treatment and care should be directed to the Third Party Administrator or Risk Management. 4. The employee must use the authorized healthcare provider unless the injury/illness occurred after the Healthcare Provider s hours of operation. 5. If the injury/illness occurred after the healthcare provider s hours of operation, the employee should obtain medical treatment at the nearest urgent care facility/hospital. As soon as possible after treatment, the employee must report to the authorized Workers Compensation Healthcare Provider as required for continued Workers Compensation treatment. Questions regarding treatment or prescriptions should be directed to Third Party Administrator and /or Risk Management. D. Healthcare Provider Employees covered under the City s Workers Compensation Program must report to the medical provider authorized by the City, unless the injury/illness requires emergency treatment at an urgent care facility/hospital or the injury/illness occurs after the healthcare provider s hours of operation. Specific information such as hours of operation, contact numbers and location, should be posted on each departmental bulletin board and the Risk Management Division. Medical treatment provided by an unauthorized healthcare provider may not be covered under the City s Workers Compensation Program. E. Workers Compensation Reports Workers Compensation reports are easily obtained from City s internet, through the Human Resources Department Risk Management Division. Supervisors are responsible for ensuring that all reports/forms are provided to the employee(s) and witnesses to complete. Supervisors shall also ensure that all of the documents are completed correctly, collected, and submitted as a complete packet to

11 Risk Management immediately following an incident. (The packet should include the following: Supervisor Investigation, Injury/Illness Report Employee Statement, Risk Management Division Memo to employee and if needed, an Incident Report Witness Statement.) First Report of Injury or Illness Report Only (Attachment 1) The supervisor and employee must complete the Accident Report of Injury or Illness report the same day but no later than the next business day after an injury/illness is reported. First Report of Injury or Illness Refusal of Treatment This report is to be used by supervisors for employees who do not wish to seek medical treatment for the injury/illness, but still need to report the possible Workers Compensation incident. a. Supervisor and employee must provide the First Report of Injury or Illness (Report Only) immediately after an injury/illness is reported. b. Employee must complete the report only, since the employee elects not to have medical treatment. c. Supervisor must fax or e-mail the report to the Human Resources /Risk Management Division. d. The original/signed report shall be mailed through interoffice mail or hand delivered to the Human Resources Department Risk Management Division immediately following an incident. 1. The Supervisor is responsible for ensuring that the following reports are immediately completed after an injury/illness occurs and/or is reported: 1. Required: Injury/Illness Report-Only ( Attachment 1) 2. Required: Injury/Illness Report Supervisor Investigation (Attachment 2) 3. Required: Injury/Illness Report Employee Statement (Attachment 3) 4. Required if witness/witnesses: Incident Report Witness Statement (Attachment4) 5. Communication between supervisor, employee, TPA Chart (Attachment 5) 6. Acknowledgement letter to employee from Risk Management Division (Attachment 6) 7. City s Authorized Medical Providers, Third Party Administrator, and Managed Care contact information (Attachment 7) 8. Time Sheet example for employees injured on the job (Attachment 8)

12 9. Post Accident Medical Center Information/ Report(s) shall be forwarded to Risk Management Division along with the First Report of Injury or Illness, including Report Only. F. City of Riviera Beach Webpage Human Resources Department Risk Management Division The Human Resources Department Risk Division webpage provides specific information and contact numbers for the City s Third Party Administrator, healthcare provider. Supervisors should provide a print out of the specific information found on the City s webpage Human Resources Department. /Risk Management Division to the employee along with the First Report of Injury or Illness Form. Supervisors should keep copies on hand that can be easily accessible in times of an emergency. To obtain this information, see the City s internet webpage www.rivierabch.com and click on Human Resources Department (/) Risk Management Division Workers Compensation in the Wellness & Safety section, and print out the entire page. F. On-the-Job Injury or Illness Flow Chart The On-the-Job Injury or Illness Flow Chart provides quick reference information on steps to take for emergency medical treatment, non-emergency medical treatment and no medical treatment procedures. (Attachment 6) G. Light/Restricted Duty The supervisor will provide light duty work assignments to any employee on restrictions due to Workers Compensation Physician recommendations. Light duty work assignments are only provided to employees who experience an on-the-job injury (ies) and/or illness (es). If the employee s department does not have a light duty work assignment, the supervisor should contact Risk Management. Risk Management will arrange with other departments for light duty assignments if available. Employees who refuse light duty work assignments will not receive Workers Compensation pay, and such employees may use their sick and annual leave, in that order, until released to regular work duty. If the employee has exhausted all accrued leave and still refuses light duty assignments, then the employee will go into a no pay status until the Workers Compensation Physician releases them to regular work duty. During this time, the employee may have reinstatement rights in accordance with the Family Medical Leave Act (FMLA), if applicable. The employee will continue light duty work assignment until released by the Workers Compensation Physician to return to regular work duties or as indicated in the respective labor contract. If no light duty assignments exist within the City, the employee shall receive indemnity benefits under the Workers Compensation program. H. Compensation and Benefits An employee who is required to be absent from work due to an on-the-job injury/illness shall be compensated as follows:

13 1. The employee time sheet will be coded WC (Workers Compensation) for the amount of time employee left work for medical treatment. 2. The employee does not use sick leave for Workers Compensation related doctor s appointments. 3. The City will pay the employee for time taken for medical treatment if it is during their regularly scheduled work hours, however the employee should make every attempt to schedule their doctor s visit around their work scheduled. 4. Workers Compensation does not pay for absences during the initial seven (7) calendar days (cumulative) following an accident. However, the City will pay the employee for the first seven (7) calendar days. Beginning the 8 th day of absence, the employee will start receiving indemnity benefits of 66⅔ of their average weekly wage. 5. Worker s Compensation will pay compensation benefits for absences beyond the first seven (7) calendar days in accordance with Florida Statutes Chapter 440. The employee may use 1/3 sick and vacation hours in that order to receive 100% of their salary. 6. City s group benefits (health insurance, life insurance, etc.) shall continue so long as the employee remains in a pay status and in compliance with the eligibility requirements of the City s and Workers Compensation Program. If the employee goes into a no-pay status, the employee will be required to make payments for their dependent portion of employee benefits premiums and voluntary benefit premiums until the employee returns to full work status. Arrangement for payments will be made with the Human Resources Department Risk Management Division. 7. All available sick leave hours must be exhausted, before accrued annual leave may be used to supplement Workers Compensation indemnity benefits. 8. Any leave associated with an on-the-job injury/illness (paid or unpaid), where the injury/illness is a serious health condition as defined in the Family and Medical Leave Act, shall be designated as Family Medical Leave (FMLA) and run concurrently with Workers Compensation leave. 9. Employees are required to report their current work status to their supervisor, as determined by the Workers' Compensation physician (in writing) immediately following each office visit. 10. Different rules apply to employees taking leave in accordance with the Family Medical Leave Act (FMLA). Please refer to the City s FMLA Policy and Procedure for additional information. 11. The employee s time sheet will be coded as follows: (see attached sample on Attachment #8) a. First seven ( 7)-days absence following the on-the-job injury/illness: WC (Workers Compensation) - Enter the number of hours used or spent at the authorized health care facility or urgent care facility. In addition, use WC when employee attends a doctor visit for Workers Compensation. b. First seven ( 7) calendar days absence from the on-the-job injury/illness for unauthorized medical provider:

14 WCS - Enter the number of sick leave hours (if available) employee uses, if unauthorized by health care provider. c. After the first seven (7 )calendar days absence following the on-the-job injury/illness: Employee has the option of supplementing 33.4% (2.37 hrs) with sick or annual leave. d. When FMLA runs concurrently with Workers Compensation: After seven (7) calendar days of absence from the on-the-job injury/illness Enter the number of sick leave /FMLA hours employee uses Enter the number of annual leave /FMLA hours employee uses Enter the number of non-paid /FMLA hours employee uses e. When employee is placed on Light Duty Work (LDW) for the on-the-job injury/illness: use LDW in the comment section. f. Employees who are on Light Duty/Modified Duty status ARE INELIGIBLE FOR OVERTIME HOURS. 12. The employee does not use sick leave for Workers Compensation related doctor s appointments. G. Executive Safety Action Team The Executive Safety Action Team and/or department managers, directors will review Injury/Illness Reports at monthly meetings and make recommendations to reduce or eliminate future Workers Compensation claims. Department needs to determine the cause of the accident. H. Further Investigation The Human Resources Department Risk Management Division may require more information than the Workers Compensation Reports provide. An investigation may be initiated by the Risk Management Division when deemed it necessary, if the information contained in the report is contradictory or lacking in detail. The TPA and/or Risk Management Division will conduct an investigation to gather more information and make recommendations for preventing future claims and possible corrective actions. V. RESERVATION OF AUTHORITY The authority to issue or revise this Procedure is reserved to the City Manager. The City Manager may authorize exceptions to this procedure when deemed appropriate.

At this time, I am refusing medical attention related to the above mentioned injury/illness. If in the future I require medical attention, I understand that I am required to report this information to my Supervisor.

Employee Signature Supervisor /Department Head Signature/ Date *Note: Please forward to Risk Management Division

16 CITY OF RIVIERA BEACH SUPERVISOR'S ACCIDENT / INCIDENT REPORT (Attachment #2) Department Division 1. CHARGEABLE YES NO 2 ACCIDENT NUMBER 7. Weather Conditions: Clear Cloudy Rain Fog Hurricane Other 8. Surface Conditions: Dry Wet Hot Other 9. TYPE OF ACCIDENT (Check One) 01 Employee Injury 03 Sewage Backage 05 Fire 07 property Damage 02 Vehicle/Equipment Damage 04 Non-Employee Injury 06 Fuel Spill 08 Other please specify 19. Job Title 20. Regular Shift 21. On Overtime 22. Date of Hire Yes No 24. Regular Days Off (Check) 25. Did employee receive medical treatment other than First Aid? S M T W T F S Yes No Female 23. No. of Years in this Position 25A. Hospital/Doctor Part-Time 26. Type of Accident (check one) 27 Nature of Injury/Illness 28. P art of Body Injured 29. Body Position When Accident Occurred Accident Occurred 01 Caught Between 10 Pulling 01 Burn 01 Foot / Toes 13 Abdomen 01 Standing 02 Caught In 11 Pushing 02 Amputation 02 Ankle 14 Back 02 Sitting 03 Fall-Differelt Level 12 Repeated Operation 03 Concussion 03 Knee 15 Eye(s ) 03 Walking 04 Fall-Same Level 13 Struck By 04 Contusion / Bruise 04 Leg 16 Ear(s) 04 Kneeling 05 Slip/No Fall 14 Struck Against 05 Crushing Injury 05 Hip 17 Face / Nose 05 Bending 06 Ingestion 15 Driving Vehicle 06 Fracture / Dislocation 06 Finger 18 Head 06 Tw isting / Turnin 07 Inhalation/Absorption 16 N / A 07 Cut / Puncture 07 Hand 19 Neck 07 Reaching / Stretc 08 Carrying 17 Other 08 Sprain / Strain 08 Wrist 20 Internal 08 Crouching 09 Lifting 09 Foreign Body (eye) 09 Elbow 21 Other 09 Craw ling 10 None 10 A rm 22 None 10 Prone 11 Dermatitis 11 Shoulder 23 Right 11 Straddle Special notes: 12 Infec. Disease Expo 12 Chest 24 Left 12 Other 13 Toxic Atmos. Expo. 13 N/A 14 Hearing Loss SUPERVISOR SIGNATURE/ NAME : 15 Unconsciousness 16 open Wound Supervisor Name (PRINT) Date

EMPLOYEE STATEMENT EMPLOYEE NAME: DATE OF INCIDENT / ACCIDENT: POSITION: DEPARTMENT: DESCRIPTION OF INCIDENT / ACCIDENT Type of Accident (check one) Nature of Injury/Illness P art of B ody Injured Body Position When Accident Occurred 01 Caught Between 10 Pulling 01 Burn 01 Foot / Toes 02 Caught In 11 Pushing 02 Amputation 02 Ankle 03 Fall-Differelt Level 12 Repeated Operation 03 Concussion 03 Knee 04 Fall-Same Level 13 Struck By 04 Contusion / Bruise 04 Leg 05 Slip/No Fall 14 Struck Against 05 Crushing Injury 05 Hip 06 Ingestion 15 Driving Vehicle 06 Fracture / Dislocation 06 Finger 07 Inhalation/Absorption 16 N / A 07 Cut / Puncture 07 Hand 08 Carrying 17 Other 08 Sprain / Strain 08 Wrist 09 Lifting 09 Foreign Body (eye) 10 None 11 Dermatitis 09 Elbow 10 A rm 11 Shoulder Special notes: 12 Infec. Disease Expo 12 Chest 13 Toxic Atmos. Expo. Left Side 13 Abdomen 14 Back 15 Eye (s ) 16 Ear(s) 17 F ac e / N o s e 18 Head 19 Neck 20 Internal 21 Other 22 None 23 Right 24 Left Right Side 01 Standing 02 Sitting 03 Walking 04 Kneeling 05 Bending 06 Twisting / Turning 07 Reaching / Stretchin 08 Crouching 09 Crawling 10 Prone 11 Straddle 12 Other 13 N / A 14 Hearing Loss Describe others: 15 Unconsciousness 16 open Wound DATE SIGNED WITNESS

18 WITNESS STATEMENT (Attachment #4) NAME & ADDRESS : DATE OF INCIDENT / ACCIDENT: TELEPHONE: TIME/ WEATHER: ACCIDENT LOCATION DESCRIPTION OF INCIDENT / ACCIDENT Witness Signature Name Date

19 Attachment # 5 = communication between supervisor, employee, TPA Emergency (911) Non-Emergency No Medical Treatment Supervisor Supervisor Supervisor First Report Injury/Illness Supervisor to: Fax or email to Risk Management Copy to Employee to take to Hospital Send to Employee Information from WC webpage given to Employee Employee Hospital City s Reports/Form s First Report Injury/Illness Supervisor Employee Witness Employee Services First Report Injury/Illness Supervisor to: Fax or email to HR/Risk Division Copy to Employee to take to Healthcare Provider or Hospital Information from WC webpage given to Employee Employee Healthcare Provider or Hospital Investigation Reports/Form s First Report Injury/Illness Supervisor Employee Witness Risk Management First Report Injury/Illness (Report Only) Supervisor to: Fax or email to Risk Management Employee on light duty or out on Workers Compensation. (FMLA runs concurrent with time out of work in excess of three consecutive calendar days.) Investigation Reports/Form s First Report Injury/Illness (Report Only) Supervisor Employee Witness Employee Services Third Party Administrator

20 Attachment # 6 RISK MANAGEMENT DIVISION MEMO TO INJURED EMPLOYEE FROM: Marie Sullin, Cassandra Wooten, and Risk Management Division SUBJECT: Workers Compensation Procedures We are sorry to hear that you were injured on the job. The City of Riviera Beach strives to create a safe working environment for all employees. Please let us know how we can assist you and help you get back to full health. Please note the following procedures in regards to a workers compensation injury: 1. Please only go to the doctor, clinic or hospital within the insurance company s network for medical treatment of your work related injury. (Information posted at your work site bulletin board). If you are unsure of the appropriate facility please contact your supervisor or Risk Management. 2. Please contact the Risk Management Division after your initial doctor s appointment either in person or by telephone. We can be reached at 561-840-4880 Monday-Friday between 8:30 a.m. and 5:00 p.m. 3. Please advise the pharmacy staff that the medication is for work related injury, and that they should contact Gallagher Bassett at 1- (877) 473-4919 Fax: (866) 436-8848. 4. If your doctor assigns you work restrictions, please provide a copy to your supervisor. Your supervisor will assign you a work assignment within your restrictions. 5. If you need transportation to and from your medical appointments due to medical restrictions, please advise us at least 24-hours in advance so that transportation services can be arranged. 6. If you have been released to restricted duty and are unable to report to work, you must follow the normal sick call procedures. 7. While on duty, if you experience further complications from your work injury, please notify your supervisor immediately. 8. Failure to comply with the City s Policies could result in disciplinary actions, up to and including termination. 9. For any additional questions or concerns, please feel free to contact the Risk Management Division. If you need to speak with us during your work shift, please ask your supervisor to schedule an appointment for you. Employee Signature Date Witness

21 CITY OF RIVIERA BEACH Attachment # 7 All employees with non-emergency injuries are to be treated CONCENTRA MEDICAL CENTER 4455 Medical Center Way West Palm Beach, FL 33407 HOURS OF OPERATION: Monday-Friday: 8:00a.m.-8:00 p.m. Saturday-Sunday: 10:00 a.m.- 4:00 p.m. Phone: 561-881-0066 Fax: 561-881-5533 AFTER HOURS EMERGENCIES COLUMBIA HOSPITAL 2201 45 TH Street West Palm Beach, FL 33407 (561) 842-6141 GALLAGHER BASSETT (TPA) P.O. Box 459004 Fort Lauderdale, FL 33345-9004 Phone: (877) 473-4919 Fax (866) 436-8848 ABL (CASEMANAGEMENT, INC.) 3389 Sheridan Street #214 Hollywood, FL 33021 1800-550-1653 Fax: 866-516-2396 After Hours Drug Testing NMS MANAGEMENT SERVICES INC. Nancy Richards 561-818-3433

22 Attachment # 8 PAYROLL TIME SHEET For consistency throughout the payroll, the departments have been instructed to shoe workers Compensation as follows: a. The City pays the employee for the first seven (7) days of injury. This example reflects first seven (7) days of injury and the use of sick leave. M T W T F REG SICK TOTAL HRS W/C W/C W/C W/C W/C 56 8.01 64.01 W/C W/C WC/S WC/S WC/S b. When an employee elects to use sick leave, this example reflects a continuing injury after first seven (7) days. Employee has no vacation and a balance of 25.03 sick hours. M T W T F TOTAL HOURS WC/S WC/S WC/S WC/S WC/S 25.03 WC/S WC/S WC/S WC/S WC/S-1 Employee elects leave 1/3 8 hrs 3 = 2.67 x 1 = 2.67 per day Workers comp pays 2/3 8 hrs - 3 = 2.67 x 2 = 55.33 per day (rounded) c. When an employee elects not to use sick leave or does not have any leave, then show as follows: M T W T F TOTALHOURS W/C / W/C/ W/C/ W/C/ W/C/ -0- (S) (S) (S) (S) (S) d. Employee may use annual leave (vac.) when all sick leave is used.

23 Attachment # 9 INJURED EMPLOYEE ACKNOWLEDGEMENT OF RECEIPT, READING AND UNDERSTANDING OF THE FLORIDA WORKERS COMPENSATION LAW Effective October 1, 2003 Florida law requires anyone seeking payment for benefits, good, or services as provided for by Florida s Workers compensation statues must attest he or she has received, read, and understand, the following statement: Any person who, knowingly and intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in Section 817.234 Florida statues. Please acknowledgement you have received, read and understand the statement in bold above by printing and signing your name in the space provided. If you fail to or refuse to sign this form, any benefits to which you may be entitled may be suspended until such time as you sign return this form to Human Resources/Risk Management Division By signing and dating below, I acknowledge I have received, read, and understand the fraud statement in bold typeface above. (Sign your name on the line above) Date (Print Name on the line above) (Provide your social security number on the line above)