RETURN TO WORK 101INJURY REPORTING

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WC Overview

Forms/Process

Completing Forms

Seeking medical treatment via Pre-designation or Initial Treatment Center (ITC)

Work Hardening (WHTAA)

Maintaining File/Contact with Employee

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Injury definition: Any injury or disease arising in the course and scope of employment

Applicable labor code section;“…shall be liberally construed by the courts with the purpose of

extending their benefit for the protection of persons injured in the course of their employment.” (LC3202)

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Third Party Administrator

Contractor hired by County of Los Angeles to administer workers’ compensation benefits for County employees

Decides whether workers’ compensation claims are compensable (work-related)

Decision must be made within 90 days of receiving claim form

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Emergency Injury Reporting

Non-Emergency Injury Reporting

Employee Seeks Treatment

Employee Injury/Illness File

Employee on Temporary Total Disability

Employee Released to Full Duties

Employee Release to Modified or Alternative Work

Required Forms5

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Once the situation is stable, you should:

1. Complete the DWC1 Claim Form, and the Employer’s Report of Injury (5020) and call into the Toll-Free number within 24 hours.

2. Complete the Job Description form.

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WORKERS’ COMPENSATION CLAIM FORM (DWC 1)

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EMPLOYER’S REPORT OF OCCUPATIONAL INJURY/ILLNESS (5020 FORM)

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JOB DESCRIPTION FORM

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JOB DESCRIPTION FORM

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FIRST ALERT FORM

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If Employee Declines Treatment:

1. Employee must complete the Employee’s Statement Declining Treatment form. A copy of the form must be sent to the RTW Coordinator or Personnel.

2. Employee must sign Receipt of Employee Packet, and be given the packet.

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Review the Employee’s Guide for Injury Reporting with the employee.

Complete the Injury Reporting forms with the employee. The packet must contain the four forms below:

1. The completed Treatment Referral Slip

2. The completed Treating Physician’s letter (for physical injuries only)

3. A copy of the blank Patient Status Report

4. A copy of the completed Job Description should be included in the Medical Provider Packet.

Send the four documents with the employee to thePre-designated physician OR ITC, as applicable.

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Ask the employee if they have Pre-designated a treating physician.

If they have not, send them to the Medical Provider Network (MPN) Initial Treatment Center (ITC).

A list of those centers can be obtained on the County’s MPN website at:http://ceo.lacounty.gov/mpn

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PREDESIGNATION OF PERSONAL PHYSICIAN FORM

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Fill out the DWC1 Claim Form, and Employer’s Report (5020) form. The injury must be called into the Toll-Free number within 24 hours upon notice of the injury.

Call the Toll-Free number and report the injury.

In some departments, the main RTW Unit staff calls in the injury, in others the supervisor or location designee calls it in.

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If Employee has not Pre-designated their personal treating physician, the work location Supervisor or designee must direct them into the County’s Medical Provider Network (MPNs), via an Initial Treatment Center (ITC).

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Location Supervisor should fax a copy of the Patient Status Report to the RTW Unit/Personnel.

Make sure that the time card is coded appropriately.

Call the employee for status. The employee should be called on a weekly basis to determine their status, follow-up on their recovery, and answer any questions they may have regarding the process.

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Return the employee to work.

Communicate with the employee to make sure they are able to continue working their Usual and Customary (U&C) duties.

The department RTW Unit should be informed of status in writing, and of any problems or concerns.

Close the employee injury/illness file in 45 days from the date of injury if the employee continues to work their U&C job.

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If a Physician has provided restrictions that prevent employee from immediately returning to their Usual and Customary (U&C) job, proceed with the following:

1. Review the work restrictions to make sure they are compatible with the duties listed in the job description.

2. If the work restrictions are compatible, return the employee to work.

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3. If the modification of the job duties is required, make the necessary modifications.

4. Communicate those temporary modifications and time limits to the employee.

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If modification of the job is done, a Work Hardening Transitional Assignment Agreement (WHTAA) must be completed with the employee. (This should be done during the Interactive meeting and by either or both the RTW Unit staff or the location Supervisor or designee along with the employee.)

Location Supervisor/designated staff and department RTW Unit staff should both have a signed copy of the WHTAA, along with the employee.

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Retain a copy of the WHTAA in the employee’s injury/illness file.

If modification of the job is not possible, explore available job tasks within the work unit.

If the location is able to provide alternative work, a WHTAA must be completed with the employee.

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If no alternative or modified job is available after a thorough and reasonable search is conducted, contact the Supervisor/Management at work location and human resources staff to assist with a plan to monitor situation and expand search for other job placement opportunities within the department.

Catalog a follow-up date with department staff.

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When an assignment is located, complete the WHTAA form with the employee on their first day back to work.

Make sure a signed WHTAA form is obtained and maintained between the department RTW Unit and the work location/supervisor/RTW Coordinator.

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If there is a problem reaching the employee at home, document attempts on the Telephone Log and work with other County TPA staff as appropriate to verify contact information. If necessary you can contact the treating physician to request medical certification reflecting any restrictions or to verify employee is taken off work.

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If you suspect any behavior or receive any information regarding fraudulent activities or abuse, this information should be shared with our TPA staff once their file is set up.

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Receipt of Employee PacketEmployee’s Statement Declining Medical TreatmentFirst Alert or other proof of Fax as appropriateDWC1 Claim FormEmployer’s Report (5020) FormJob Description FormTreating Physician’s LetterTreatment Referral SlipWork Hardening Transitional Assignment AgreementWeekly Call Verification SheetTo locate more forms see:http://ceo.lacounty.gov/mpn

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Complete DWC-1 Employee Claim Form

Complete Employee’s Report of Accident

Return the Completed forms to your supervisor/including all Medical Certifications from your treating physician

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It is important that an injury/illness file bemaintained on employees. The injury/illnessfile should contain, at a minimum, the followingdocuments:

A copy of the Claim Form (DWC Form 1)A copy of the Employer’s Report (5020)Copy of the Job Description/Essential Job Functions listingEmployee’s Report of AccidentPatient Status ReportsWork Hardening AgreementsSupervisor Weekly Telephone Log SheetAny other documentation that you may receive on this injury

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