WHAT SHOULD I DO IF I HAVE A WORK-RELATED INJURY? 1) In a serious emergency, call 911 or go to the nearest hospital/trauma center! Follow-up care is to be arranged with one of the district s designated medical providers listed below. If the injury is not a serious emergency but occurs after hours and you need to be seen by a physician, you are authorized to go to the nearest urgent care facility. Follow-up care is to be arranged with one of the district s designated medical providers listed below. 2) If the injury is not a serious emergency, you must contact Human Resources (Beth Collins at 720-561-5936 or beth.collins@bvsd.org) to make arrangements to see one of the district s designated medical providers listed below. You are not authorized to see your personal physician and have Workers Compensation pay the claim. Human Resources will assist you with your appointment. The Employee Report of Injury/Incident (available on the BVSD website at http://bvsd.org/benefits/pages/workerscompensation.aspx and in Human Resources) must be filed through Human Resources in order for your bills to be eligible to be paid under Workers Compensation. 3) Notify your supervisor. 4) You will be seen by the district s designated medical providers. You must select a designated provider from the list in the table: One Walden Building 4790 Table Mesa Drive Boulder, CO 303.443.0496 290 Nickel Street Broomfield, CO 303.460.9339 Boulder Community Hospital Occupational Health and Therapy Services 4745 Arapahoe Avenue Suite G40 Boulder, CO 80303 720.854.7854 M-F 8:00 AM 4:30 PM By Appointment By Appointment By Appointment 5) It is your responsibility to inform Human Resources (Beth Collins) and your supervisor of your progress and any time off work. Workers Compensation will not pay for time off work that is not authorized by the district s designated medical provider. If you cannot return to your regular duties, alternative duties may be temporarily assigned. Questions? Call Human Resources (Beth Collins) at 720-561-5936. We ll help you through your injury and back to work! WHAT SHOULD I DO IF I HAVE A WORK-RELATED INCIDENT? If you experience a minor injury or an incident whereby you don t need medical treatment, you still need to report it. Please follow the process listed below. 1) Notify your supervisor. 2) Call Human Resources (Beth Collins) at 720-561-5936 and complete Employee Report of Injury/Incident (form #2) of the packet titled, Workers Compensation Information and Forms, available through Human Resources or on the BVSD website http://bvsd.org/benefits/pages/workerscompensation.aspx and return to Beth Collins in Human Resources. Workers Compensation Form #1 08//01/09
EMPLOYEE REPORT OF INJURY/INCIDENT (TO BE COMPLETED BY EMPLOYEE) DATE OF REPORT: DATE OF INJURY/INCIDENT: NAME OF EMPLOYEE: WORK SITE (WHERE INJURY/INCIDENT OCCURRED): WORK PHONE: I certify that the following statement is a true and accurate account of the events that happened: Employee Signature: Was there a witness(es) to the injury/incident? Yes No If yes, please provide name(s) of witness(es): I received the Designated Provider information, Workers Compensation Form #3 included in this packet. Employee Signature: Workers Compensation Form #2 061808
Boulder Valley School District DESIGNATED PROVIDER LIST In a serious emergency, call 911 or go to the nearest hospital/trauma center! Follow-up care is to be arranged with one of the district s designated medical providers listed below. If the injury is not a serious emergency, you must contact Human Resources (Beth Collins at 720-561-5936 or beth.collins@bvsd.org) to make arrangements to see one of the district s designated medical providers listed below. You are not authorized to see your personal physician and have Workers Compensation pay the claim. Human Resources will assist you with your appointment. One Walden Building 4790 Table Mesa Drive Boulder, CO 303.443.0496 290 Nickel Street Broomfield, CO 303.460.9339 Boulder Community Hospital Occupational Health and Therapy Services 4745 Arapahoe Avenue Suite G40 Boulder, CO 80303 720.854.7854 M-F 8:00 AM 4:30 PM BVSD s claims administrator responsible for Workers Compensation is CCMSI. The following are designated as BVSD and administrator representatives: Beth Collins, Workers Compensation Specialist Human Resources Boulder Valley School District PO Box 9011 6500 Arapahoe Boulder CO 80301 Phone: 720.561.5936, Fax: 720.561.5217 Paula Lowder, Claims Adjuster CCMSI PO Box 4998 Greenwood Village CO 80155 Phone: 303.804.2024, Fax: 303.804.2005 The EMPLOYEE REPORT OF INJURY/INCIDENT must be filed through Human Resources in order for your bills to be eligible to be paid under Workers Compensation. This list was provided to by on, by month date year Hand-delivery U.S. mail E-mail Facsimile Other Signature of Employer Representative Date Workers Compensation Form #3 080109
Boulder Valley Schools Supervisor s Accident/Incident Investigation Report To be completed by the Supervisor See Next Page for Instructions School/Department: Name of Person Completing Form: I. General Information II. Description Employee Name: Job Title: Employee Number: Sex: M F Date of Accident/Incident: Time of Accident/Incident: AM PM Type of Accident/Illness/Incident: Type of Injury/Incident: Part of Body Injured: Treatment: First Aid Medical Where? Where and how did accident/incident happen? (Please provide brief description.) Name(s) of Witness(es): Did Employee Return to Work the Same Day? Yes No Specific employee act, (action, task or activity) connected with the accident/incident: Unsafe condition at time of accident/incident (please be specific): III. Causes Unsafe personal factors at time of Accident/Incident: Personal Protective Equipment (PPE) required, i.e. eye, hand, foot protection, etc.: Was employee using required PPE? Yes No Action plan to prevent recurrence (modification of machine, mechanical guarding, environment, training): IV. Recommendations Supervisor's name (please print) Supervisor s signature Actions taken on recommendations (include date completed, if possible): Date V. Follow-up Send Form to Human Resources ASAP, and File One Copy at Your Department/School for Safety Use and Review Workers Compensation Form #4 061808
Instructions For Completing Accident/Incident Report (on reverse side) Please print or type all information. Complete report in as much detail as possible. I. General Information Fill in all information requested: Name of person injured, date, exact location, job title, job being performed, etc. For description of type of accident/illness/incident, injury, and body part, see the following: A. Type of Accident/Illness/Incident slip/fall struck by/against caught in/on/between contact with/by/hot object/electric current overexertion/lifting/carry/hold/ push/pull cut by amputation inhalation injured by hand tool not powered/or by power tool B. Type of Injury cut bruise puncture abrasion strain sprain burn irritation swelling fracture C. Part of Body Injured (select as many as needed) thumb/finger/hand/wrist elbow/arm/shoulder toe/foot/ankle leg/knee/hip head/neck/face nose/eye/ear/throat chest/abdomen upper back/lower back respiratory II. III. IV. VI. Description of Accident/Incident Describe in as much detail as possible where and how the Accident/Incident happened. This section is for facts, not opinion. Statements the injured or witnesses made should be detailed. Use an additional piece of paper if more space is needed. Include sketches or photos if they help explain what happened. Accident/Incident Causes (see casual factors below) Unsafe Acts, Conditions, and/or Personal Factors involved. Recommendations Once causes are identified, action must be taken to prevent the same thing from happening again. Realistic, yet effective, recommendations should be implemented. The form should be signed and dated by the appropriate supervisor. Follow-up List actions that have been taken and their respective completion date. Proper follow-up should continue on any incomplete recommendations. A) Unsafe Act 1. Working or operating without authority 2. Working at unsafe speeds 3. Making safety devices inoperative 4. Taking unsafe position or posture 5. Unsafe manual materials handling 6. Using defective tools 7. Using hands instead of tools 8. Unsafe loading or unloading 9. Failure to use personal protective equipment (Be Specific) 10. Distracting, teasing or horseplay 11. Not following rules or instructions 12. Other (Give complete details) 13. No unsafe act Accident/Incident Causal Factor(s) B) Unsafe Condition 1. Improperly guarded 2. Safety devices inoperative 3. Defective 4. Hazardous arrangement (incl. poor housekeeping) 5. Improper illumination 6. Improper ventilation 7. Lack of suitable personal protective equipment 8. Unsafe dress or apparel 9. Hazardous dust, gases or fumes 10. Other (Give complete details) 11. Environmental (i.e., wet, icy, slippery, hot, cold, etc.) 12. No unsafe condition C) Unsafe Personal Factor 1. Improper attitude 2. Lack of required safety knowledge or skill 3. Defective eyesight 4. Defective hearing 5. Fatigue 6. Muscular weakness 7. Pre-existing heart weakness 8. Pre-existing hernia 9. Intoxicated (under the influence of alcohol, drugs, etc.) 10. Other (Give complete details) 11. Slow reaction time 12. No unsafe personal factor Workers Compensation Form #5 061808