Occupational Injury / Illness Report This report must be completed whenever a Franklin & Marshall employee, including a student worker, is injured or becomes ill during the course of his/her employment with the College. Based on OSHA requirements, the employee/student worker must answer ALL questions and sign and date this form, have his/her manager sign the form, and return it to Human Resources within 24 hours of the injury or onset of illness. Name of injured/ill employee (please print): Job Title: Department: Your Home Address: Home Phone #: Primary Care Physician: Date of Birth (required): College ID #: Male Female Manager s Name: Manager s Work Phone #: Are you employed by another company? If so, please provide the name of all other employers: Date of injury or onset of illness: Time injury or illness occurred: Scheduled hours of work on day of injury (i.e., 7:30 a.m. 3:30 p.m.): Please provide a description of the injury/illness, including specific body part(s) affected and type of injury/illness (i.e., low back strain, laceration to right hand, burn to left shoulder, etc.): body part(s) injured (be specific; include right or left side of body): type of injury/illness: What were you doing when the injury/illness occurred or when you first noticed symptoms? Where were you when the injury/illness occurred or when you first noticed symptoms? (over)
What caused this injury/illness? If applicable, what object or substance caused the injury? Were you working with anyone when the incident occurred? If so, please provide the name of the individual(s): Have you had this type of injury/illness before? Have you received medical treatment for this injury/illness? If so, when? If yes, please provide the name and address of the medical care provider: If you have been absent from work due to this injury/illness, please provide the date(s) you have been absent: What do you think can be done to prevent a similar injury/illness from occurring (i.e., equipment changes, procedural changes, protective equipment, etc.)? What corrective action has been taken to prevent a similar incident? (You and/or your manager are asked to initiate corrective action, as appropriate, by contacting Facilities & Operations.) Please note: If you are absent from work for a full day/shift due to this injury or illness, please notify Human Resources, 291-3902, on the first day you are absent from work. Signature of employee: Signature of manager: Date: Manager s email: Signature of department manager or department chair: Please return to Human Resources, College Square or FAX: (717) 291-3969 within 24 hours of the incident. For Human Resources' Use: Date incident first reported: Fatal injury: Yes No Employee Category: TO: FROM: DATE OF HIRE SSN # OF PAGES: to RCM&D, FAX: (800) 706-9344 SCAN COPY TO: F&M Director of Environmental Health & Safety REMOVE SSN BEFORE SCANNING UPDATED 1/24/2014 PW
Workers' Compensation Notice and Panel of Physicians Workers' Compensation is designed to provide wage loss benefits and reimbursement for reasonable medical care expenses to an employee who is injured, or becomes ill, through the course of his/her employment. Notification of a Work-related Injury or Illness: If a College employee is injured while performing his/her job duties, or suffers an injury or illness as a result of the workplace or tasks that the employee must perform, he/she must: (1) report the injury to his/her manager and to Human Resources, (717) 291-3996, no later than within 24 hours of the injury or onset of illness, and (2) complete an Injury Report Form for Work-related Injury or Illness immediately following the injury, whenever possible, and no later than within 24 hours of the injury. The Injury Report Form must be signed by the employee's manager, and then promptly submitted to Human Resources. If the employee is unable to report the injury and complete an Injury Report Form due to the injury, the employee's manager must contact Human Resources and must complete the form to the best of his/her ability, on behalf of the injured employee. Student workers injured while performing work for wages for the College must report injuries to Human Resources (291-3996) and to their manager, and must complete an Injury Report Form. The Injury Report Form is available from Human Resources and on the following web page: www.fandm.edu/humanresources/article/all-forms-complete-list. If an employee or student worker is absent from work for a full day or shift due to a work-related injury or illness, the employee is required to notify Human Resources (291-3996) on the first day he/she is absent from work. Workers' Compensation Benefits: Benefits are provided to employees who incur injuries or illness arising from, and in the course of, their employment. In the event of a compensable work-related injury or illness, employees are entitled to reimbursement for reasonable and necessary surgical and medical services and supplies, and orthopedic appliances and prosthesis, including training in their use. If an employee has an approved absence due to an occupational injury or illness, wage loss benefits will be provided in accordance with PA Workers' Compensation law. Such wage loss benefits are not intended to replace full salary. An employee may not use paid sick days and/or paid vacation days on any day(s) he/she receives wage loss benefits per the Workers' Compensation Act. An employee may, however, use any earned paid sick days or paid vacation days during a waiting week. If Workers Compensation wage loss benefits become payable retroactive to the first day off work, Workers Compensation wage loss payments must be turned over to the College if the employee has already received full base salary via paid sick leave or paid vacation. However, in no case will an employee receive less net (after-tax) wages than what is required per the PA Workers Compensation Act. Family & Medical Leave, if applicable, will run concurrently with any necessary, approved time off work. Family & Medical Leave will be considered unpaid when an employee is receiving income through Workers Compensation. Fringe benefits coverage for an eligible full-time employee will be provided if the employee is eligible for Family & Medical Leave, per the College s Family & Medical Leave Policy. When Workers Compensation wage loss benefits are paid, benefits coverage is per policies pertaining to an unpaid Family & Medical Leave. Under the Workers' Compensation Act, prescription reimbursement is limited to 110% of the average wholesale price of the medication. If an employee must purchase prescription medication due to a work-related injury or illness, he/she should notify the pharmacist that the prescription is for a work-related injury and check to be sure that the charge is within the reimbursable limit. (over)
Modified Work Duties: When applicable, the College will strive to provide modified work duties, on a temporary basis, to an employee who has experienced an occupational injury or illness. The College reserves the right to temporarily transfer an employee to another office or department on campus in order to provide productive modified-duty work. When determining the type of work the employee can perform, the College will rely on instructions from the employee s health care provider, as well as the employee s experience and abilities. An employee performing modified duties will generally receive his/her normal base wages, if working the same number of hours and days per week as prior to the injury or onset of illness. Wages will be prorated if working less than a full schedule, but will be no less than what is required per the PA Workers Compensation Act. Modified duties will typically be provided for up to a 3 month period. Medical Treatment Following a Work-related Injury or Illness: The College has selected a panel of at least 6 physicians and other health care providers who are available to treat your work-related injury or illness during the first 90 days of treatment. This list of health care providers is posted at Franklin & Marshall College and a copy is attached to this form. If you are injured at work or suffer an occupational illness, you have certain legal RIGHTS and DUTIES under Section 306 (f.1)(1)(i) of the Workers Compensation Act regarding your medical treatment. These rights and duties are summarized below. MEDICAL TREATMENT DURING THE FIRST 90 DAYS Ø You have the right to receive reasonable and necessary medical treatment for your work injury or occupational illness. Your employer (the College) must pay for the treatment, as long as the treatment is by one of the College s listed providers. Ø You have the right to choose which of the listed providers will treat you for your work injury or illness. Ø You have the right to switch among any of the listed providers when you receive treatment, and if a listed provider refers you to a provider not on your employer s list, you have the right to receive treatment from the referral provider. Ø You have the right to receive emergency medical treatment from any provider. However, non-emergency treatment must be given by a listed provider. Ø If a listed provider prescribes surgery for you, you have the right to receive a second opinion from any provider of your choice. If that opinion is different from the opinion of the listed provider, you have the right to choose which course of treatment to follow. If you choose the treatment prescribed in the second opinion, you must receive the treatment from a listed provider for a period of 90 days after the date of your visit to the provider of the second opinion. Ø You have the duty to visit one or more of the listed providers for the first 90 days of treatment for your work injury or illness if you expect your employer to pay for the medical treatment you receive. Ø If you seek treatment for your work injury or illness from a provider who is not on the list, your employer may not have to pay for this medical treatment during the 90-day period. Therefore, you should talk to your employer (via the Franklin & Marshall Human Resources office, (717) 291-3996) before seeking treatment from a provider who is not on the list. Important: The requirements your employer must meet to have a valid list of at least 6 providers are shown below. If the list does not meet the requirements, it is not a valid list and you have the right to seek medical treatment for your work injury or occupational illness from any health care provider of your choice.
MEDICAL TREATMENT AFTER THE FIRST 90 DAYS Ø You have the right to receive treatment from any physician or other health care provider of your choice, whether or not they are listed on your employer s provider list. Your employer must pay for this treatment, as long as it is reasonable and necessary for your work injury or occupational illness and has been properly documented by the physician or other health care provider. Ø You have the duty to notify your employer if you receive treatment from a physician or other health care provider who is not listed by your employer. You must notify your employer within five days of the first visit to any provider who is not on your employer s list. The employer may not be required to pay for treatment received until you have given this notice. In a medical emergency, an employee should go immediately to a hospital emergency room for treatment, or may seek immediate treatment from a health care provider of his/her choosing. However, the employee must see one of the health care providers listed below following the emergency, in order for medical expenses to be covered. Your signature on this form indicates that you have been informed of and you understand these rights and duties. If you have questions, be sure you have your rights and duties explained to you before you sign. I HAVE BEEN INFORMED OF MY MEDICAL TREATMENT RIGHTS AND DUTIES WTH REGARD TO WORK- RELATED INJURIES AND OCCUPATIONAL ILLNESSES. THIS NOTICE WAS PRESENTED TO ME AT (check one): Time of hire When I was injured Other: Employee s Signature Date Employer s Signature Date
Designated Health Care Providers for Work-related Injury or Illness Appel Health Services - student workers only (primary care) Franklin & Marshall College, (717) 291-4082 Basciano, Hickes, & Byers (physical therapy) 30 West Orange Street, Lancaster, PA, (717) 397-6964 Concentra Medical Center (occupational medicine, primary care, physical therapy) 113 Butler Avenue, Lancaster, PA, (717) 391-3087 (8:00 a.m. - 5:00 p.m., Monday - Friday) Department of Emergency Medicine, Lancaster General Health - for emergencies and after-hours care only (emergency care) 555 N. Duke Street, Lancaster, PA, (717) 299-5511 Department of Emergency Medicine, Lancaster Regional Medical Center - emergencies and after-hours care only (emergency care) 250 College Avenue, Lancaster, PA, (717) 291-8211 Lancaster General Health Occupational Medicine (occupational medicine, physical therapy) LGH Health Campus, 2110 Harrisburg Pike, Suite 21, Lancaster, PA, (717) 290-3155 MedExpress (urgent care) 4 Rohrerstown Road, Lancaster, PA, (717) 299-3627 Mountville Family Practice Associates (primary care) 2 College Avenue, Mountville, PA, (717) 285-3144 Novacare (physical therapy) 327 N. Duke Street, Lancaster, PA, (717) 397-7505 Orthopedic Associates of Lancaster (orthopedic specialist) 170 North Pointe Blvd., Lancaster, PA, (717) 391-2496 and 212 Willow Valley Lakes Dr., Suite 201, Willow Street, PA, (717) 517-5043 WORKNET Occupational Medicine (occupational medicine, primary care; shuttle service available between WORKNET and campus) 241 Rohrerstown Rd., 2nd Floor, Suite 200, Lancaster, PA, (717) 431-1770 Please note: Medical bills for a work-related injury or illness must be submitted directly by the medical care provider to the College's Workers' Compensation third party administrator: UCIC Claims Department, P.O. Box 90, Mechanicsburg, PA 17055, FAX: (800) 706-9344, phone: (800) 641-6330, (717) 796-1469. Bills should not be submitted to the College s health plan administrator or to Human Resources. (over)
Requirements for Employer s List of Health Care Providers 1. There must be at least 6 health care providers on the list, but there may be more than 6 listed. 2. At least 3 of the health care providers on the list must be physicians. 3. No more than 4 of the health care providers on the list may be coordinated care organizations (CCOs). 4. The names, addresses, phone numbers and areas of medical specialties of all health care providers must be included on the list. 5. The health care providers on the list must be geographically accessible and must have specialties that are appropriate based on the anticipated work-related medical problems of employees. 6. Your employer must specify on the list if any of the health care providers on the list are employed, owned, or controlled by your employer or its workers compensation insurance company. NOTE: Your employer s list of health care providers must meet all of the above requirements. IF the list does not meet all of these requirements, you do not have to choose a provider from the list. Instead, you have the right to seek medical treatment with any health care provider of your choice. In a medical emergency, the employee should go immediately to a hospital emergency room for treatment, or may seek immediate treatment from a health care provider of his/her choosing. The employee must see one of the health care providers listed below following the emergency, in order for medical expenses to be covered. BUREAU OF WORKERS COMPENSATION HELPLINE INFORMATION CENTER: 1-800-482-2383 (long-distance calls inside PA) (717) 772-4447 (local and calls outside PA)
Medical and Workers Compensation Claim Authorization I authorize any medical/mental health care provider, pharmacy, insurance company, or employer having information as to the diagnosis, treatment, and/or prognosis with respect to an occupational injury or illness for which I have filed a Workers Compensation claim to provide such information to the Shared Services Claims Department to which I am submitting a claim, or to its legal representative. I also authorize and direct the Department of Labor and Industry, Bureau of Worker s Compensation Division to furnish the Shared Services Consortium (SSC) and/or their representatives with copies of any and all information requested regarding any Workers Compensation claims that I have filed. I understand the information obtained through this authorization will be used by SSC to determine eligibility for PA Workers Compensation benefits. Any information obtained through this authorization will be released as necessary only for the processing of my claim, including any proceeding arising out of my claim. I know that I may request a copy of this authorization. I agree that a photographic copy of this authorization shall be as valid as the original. I agree this authorization shall be valid for the duration of my claim. Employee s Signature Date (over)
Additional Workers Compensation Information The Workers Compensation Act provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid. You should report immediately any injury or work-related illness to your employer. Your benefits could be delayed or denied if you do not notify your employer immediately. If your claim is denied by your employer, you have the right to request a hearing before a Workers Compensation Judge. The Bureau of Workers Compensation cannot provide legal advice. However, you may contact the Bureau of Workers Compensation for additional general information at: Bureau of Workers Compensation 1171 South Cameron Street, Room 103 Harrisburg, Pennsylvania 17104-2501 Telephone No. within Pennsylvania: 800-482-2383 Telephone No. outside of this Commonwealth: 717-772-4447 TTY-800-362-4228 (for hearing and speech impaired only); www.state.pa.us, Pa keyword; workers comp. Also attached to this sheet is a complete list of panel physicians and medical providers for your reference. I,, employee of Franklin & Marshall College (employer), certify that I have been provided with, read, and understood the information set forth above consistent with the requirements of the Pennsylvania Workers Compensation Act. Signature of employee: Date: