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Supervisor’s Workers' Compensation Reporting Instructions

Supervisor's Workers' Compensation Reporting Instructions

Supervisor's Reporting Instruction Chart (link to pdf)

 

1. Obtain a Workers' Compensation reporting packet.

The packet should contain three forms.  The 3 forms must be completed within 24 hours of knowledge of the employee's injury.

 

2. Complete the Workers' Compensation Claim Form (DWC 1).

A. The employee should complete the top portion.

B. You should complete the bottom portion.

C. You can leave Item 15 (Insurance Policy Number) blank.

D. Sign the form.

E. This form is mainly for the employee. The back of the form explains the employee's rights and benefits. Point out this information to the employee.

F. Give a copy of the form to the employee. They should take it with them to the SFO Medical Clinic or Pre-designated doctor.

 

3. Complete the Employer's Report of Occupational Injury or Illness (5020).

A. This form must be completed by the supervisor, not the injured employee.

B. To answer Item 11, be sure to have the employee contact you either personally or by phone after he/she returns from the SFO Medical Clinic.

C. The supervisor should have enough information about the injured employee to write up the Employer's Report.

 

4. Complete the Microsoft Office document iconSupervisor's Incident Investigation Report (SIIR) form.

A. If the employee is taken off of work by the treating physician and more information is needed to complete the SIIR, the supervisor should contact the employee at home.

B. If the "Employee Input" or "Corrective Actions" section is not completed, the form will be returned.

 

5. Distribution of forms

A. Ensure that the 3 forms listed above have been signed and dated.

B. Send the completed copies (originals) of the 3 forms to the Safety and Health Department (Engineering Building) within 24 hours.

C. Keep a copy of the 3 forms for your files.

 

6. SFO Clinic and Other Doctor Appointments

When the employee returns from the SFO Clinic or other doctor appointments,

the employee must provide the Physician's Report (PR-2) or Work Status

Report to you . A copy of this documentation (and future documentation) should be forwarded to the Safety and Health Department.

A. If the employee is released with restrictions, you should determine if the restrictions can be met within your shop/section. If the restrictions can be met, write a note on the form stating that the restrictions have been met and forward the documentation to the Safety and Health Department.

B. If the restrictions cannot be met, check with your supervisor/manager to determine if a different modified duty assignment can be provided to the employee. If no modified duty assignment can be identified within your C:\Documents\WC Reporting Instructions 3.15.05.doc3/24/05 section, contact the Safety and Health Department (821-5907) so that they may search for a temporary assignment outside your section. In most instances, we should be able to provide a temporary assignment.

C. If no modified duty assignment can be identified, then the employee is to be placed off of work. You should notify the Safety and Health Department by phone (821-5907) and forward a copy of the PR-2 to the Safety and Health Department with a separate note stating that the restrictions could not be met and why.

D. If the employee is initially taken off of work, the Safety and Health Department is to be notified by phone (821-5907) and a copy of the PR-2 is to be forwarded to the Safety and Health Department.

In all instances, the employee has the responsibility to stay in communication with the Supervisor and to provide the Supervisor with an updated PR-2 or work status report after each medical appointment.

 

7. First Aid Incidents

A. The Supervisor's Incident Investigation Report (SIIR) form should be completed for first aid injuries. This is to document that the employee had a minor injury but did not seek medical attention.

B. Under Severity of Incident on the SIIR form, check the box for First Aid Injury/Illness.

C. Send the completed copy of the SIIR form to Safety and Health Department (Engineering Building) within 24 hours.

D. Keep a copy of the SIIR form for your files.

E. The Workers' Compensation Claim Form (DWC-1), and the Employer's Report of Occupational Injury or Illness (5020) do not have to be completed if only first aid was administered and/or the employee did not seek medical attention.

F. If at a later date the employee needs medical attention, the SIIR can be used to complete the remaining two forms.

 

8. Pre-Designation of Physician, Chiropractor, or Acupuncturist

A. If an employee has completed a Pre-Designation of Physician Form to see his/her primary care physician prior to the injury, he/she does not need to go to the Clinic and can go to his/her pre-designated doctor.

B. If the employee has pre-designated a chiropractor or acupuncturist, they must first seek treatment either at the SFO clinic or with their predesignated personal physician. The physician must refer the employee for chiropractic or acupuncture care.

C. The employee must contact the Safety and Health office once the referral has been made so the proper notification can be made to the Workers' Compensation Division. If you have any questions on these requirements or other Workers' Compensation issues, please contact the Safety and Health Department at 821-5907