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CALIFORNIA SANITATIONRISK MANAGEMENT AUTHORITY

WORKERS’ COMPENSATION MANAGEMENT PROGRAM

INSTRUCTION MANUAL

Created by HT Consulting© 2006

CALIFORNIA SANITATION RISK MANAGEMENT AUTHORITYWORKERS’ COMPENSATION MANAGEMENT PROGRAM

All materials© 2006 HT Consulting

Except materials indicated by© 2004 Lynch & Associates/ Revision 1/2006

in the footer

All material contained in this program is protected and may not be reproduced without the express, written consent of HT Consulting or Lynch & Associates. This program, including procedures, forms, letters, reference materials and guidelines, was created for California Sanitation Risk Management Authority and may not be shared, loaned or otherwise given to any other entity, company or organization without the express, written consent of HT Consulting or Lynch & Associates.

In the development of this program, a concerted professional effort was made to ensure the accuracy of the contents; however, no warranty is express or implied. This program should not be regarded as a substitute for the advice and counsel of an attorney.

For any questions regarding the copyright or contents of this program, contact HT Consulting at (925) 922-0305.

CSRMA: Workers’ Compensation Management ProgramInstruction Manual

TABLE OF CONTENTS

I. Introduction A. Introduction to the ProgramB. Program OverviewC. Overview of the California Workers’ Compensation SystemD. Workers’ Compensation Management FlowchartE. Contact List

II. Before an Injury Happens: Getting Ready Checklist

III. Before an Injury Happens: Detailed InstructionsA. IntroductionB. Workers’ Compensation Posting Notices

a. Explanationb. Examples

C. New Hire Notification Requirements for Workers’ Compensationa. Explanationb. Personal Physician Pre-designation/Emergency Contact Information

D. Medical Provider Network (MPN)a. Explanationb. Notification Requirementsc. Initial Written Employee Notification Re: Medical Provider Network

E. Online Claim Reporting AccessF. Preparing the Documents/Forms for this ProgramG. OSHA Log Requirements

a. OSHA 300 Log Maintenance: Explanation and Requirementsb. OSHA 300 Log Posting: Explanation and Requirementsc. OSHA 300 Log: Exampled. OSHA 300A Summary: Example

H. Injury and Illness Prevention Program (IIPP): Explanation and Guide for Development

I. Other Cal/OSHA Requirementsa. Checklist b. Top Three Easiest OSHA Violations to Avoid

© 2006 HT Consulting Page 3


J. Job Description Review Guidelinesa. Job Description Overviewb. How to Review a Job Descriptionc. Definitions of Physical Demands

K. Training and Educationa. Overviewb. CSRMA Web-based Training Modulesc. Training Acknowledgment

IV. When an Injury Occursa. Overview of Workers’ Compensation Toolsb. Overview of Roles and Responsibilitiesc. How to Complete the DWC-1 Formd. Online 5020 Instructionse. Additional Instructions for Completing the 5020 Formf. 5020 Employer’s Report of Occupational Injury or Illness

V. Forms, Letters and GuidelinesA. Initial Injury/ Claim Reporting Forms

a. New Claim Information Coversheetb. Notes Pagec. Employee Wage Statement

B. Return to Work Forms, Letters and Guidelinesa. Work Abilities Memob. Guidelines for When to Send the Work Abilities Memoc. Employee Status Reportd. Treating Physician Communication Guidelinese. Transitional Task Matrix (VSFCD)f. Transitional Assignment Description Formg. Transitional Assignment Agreementh. Two-Week Transitional Assignment Reviewi. Telephone Contact Form and Guide

C. Stress Claim Procedure Forms and Lettersa. Treating Physician Memo: Stress Related Claimb. Employee Status Report: Stress Related Claim



D. Interactive Process Forms, Letters and Guidelinesa. Interactive Process: Accommodation Worksheetb. Job Opportunities Letterc. Job Opportunities Response Formd. Notice of Offer of Modified or Alternative Work (For Dates of Injury Before

1/1/04)e. Notice of Offer of Modified or Alternative Work (For Dates of Injury On or After

1/1/04)f. Letter to TPA: Modified/Alternative Offerg. Modified/Alternative Offer Acceptance Letterh. Letter to TPA Re: No Modified or Alternative Placement Available



INTRODUCTION TO THE PROGRAM

What is the WC Management Program and why should I do it?This program is designed to help you comply with various State and Federal laws that mandate certain employer responsibilities. This program goes beyond compliance to provide the necessary information, tools and resources to assist you in effectively managing your workers’ compensation process. This program focuses on that which is mutually beneficial to the employer and employees – expediting recovery and facilitating a successful return to work.

What is included in the Program?This program is broken down into seven components for ease of use. These are:

Instruction Manual New Hire Packet Exposure Packet Declination of Medical Treatment (DMT) Packet Initial Injury Packet Supervisor Checklist Workers’ Compensation Coordinator (WCC) Checklists Reference Guide

How Do I Get Started?1. Read this Introduction to the Program2. Designate a Workers’ Compensation Coordinator (WCC)3. Review and complete checklist items included in the Before an Injury Happens portion of this

program4. Complete the materials/forms preparation and distribution described on Page 35 of the Instruction

Manual.5. Review the Workers’ Compensation Management Flowchart (on page 12 of this document) to

familiarize yourself with the overall process. Note the boxes with page references. These will guide you in more detail at each step as needed.

6. Familiarize yourself with the materials contained in the various packets and checklists noted above.7. Browse the remainder of the Instruction Manual and the Reference Guide so that you know

what is available when you need it.8. Familiarize yourself with the Contacts List included in the Instruction Manual on page 13.

These are the resources available to you to help you through the process. That way when a situation/injury occurs you will know where to find assistance quickly.

9. Contact HT Consulting at (925) 922-0305 or [email protected] if you: Have any questions about this program Would like “Jump Start” training—a quick one-on-one training session to help you get

started Desire help with any specific workers’ compensation situation, claim or problem



PROGRAM OVERVIEW

PurposeThis Agency has implemented a comprehensive Workers’ Compensation Management Program in order to provide Employees with the opportunity to recover quickly, minimize wage loss and maintain a level of productivity after a work-related injury or illness. The program was developed through our Joint Powers Authority, the California Sanitation Risk Management Authority (CSRMA), which coordinates the Risk Management efforts of member wastewater facilities in the State of California. The Workers’ Compensation Management Program will enable the Agencies in CSRMA to effectively manage Workers’ Compensation losses and contain the direct and indirect costs of occupational injuries and illnesses. ProcedureThe Agency will provide injured Employees with the opportunity to return to work as soon as possible after an injury or illness. The Employee will complete an Initial Injury Packet with their Supervisor to thoroughly document the incident, obtain a treatment referral, and receive information about workers’ compensation and the return to work process. The injured Employee’s treating physician will be asked to play a major role in the process by providing the Agency with detailed information regarding the Employee’s physical capabilities. If the injured Employee is capable of performing the Usual & Customary position, then the Employee will be returned to work immediately. If the injured Employee is not capable of performing full duties, then the Employee’s Department will attempt to develop a Transitional Assignment by either making temporary modifications to the Usual & Customary position or identifying transitional tasks that fit within the Employee’s work abilities. The Department will work with the Employee, the Workers’ Compensation Coordinator and/or Upper Management to identify an appropriate assignment. Transitional Assignments are temporary and will be provided to injured Employees who will benefit from the rehabilitative nature of transitional work and contribute to the productivity of the Agency. Employees in Transitional Assignments will work at their regular rate of pay. Transitional Assignments are monitored periodically with the goal of returning the injured Employee to their Usual & Customary position. Roles & ResponsibilitiesThe program is built on a team effort approach by all Employees, Supervisors, Department Managers, the Workers’ Compensation Coordinator, the General Manager and the Third Party Administrator as overseen by CSRMA. The active participation of all team players is necessary to achieve the goal of successfully returning an injured Employee to work as a healthy and productive member of the Agency.

In the event of a work-related injury/illness, the Employee will complete an Initial Injury Packet with their Supervisor. The Supervisor will ensure that the Employee receives appropriate care and assistance. The injured Employee is responsible for providing the Agency’s Workers’ Compensation Coordinator with an updated Employee Status Report after each medical appointment. The Workers’ Compensation Coordinator will review the Employee Status Report and the injured Employee’s Usual & Customary position and will work with the Employee, the Supervisor and the Department Manager, if necessary, to identify modifications or a Transitional Assignment to return the Employee to work. The Supervisor and the Workers’ Compensation Coordinator will maintain a positive and constant flow of communication with the injured Employee while helping the Employee to return to work when medically appropriate. The Workers’ Compensation Coordinator conducts regular file reviews with the Third Party Administrator, and oversees the management and closure of Workers’ Compensation claims. If an Employee becomes permanently disabled and is unable to return to the Usual & Customary position, the Workers’ Compensation Coordinator and/or Upper Management will engage in an interactive process with the Employee to identify a Modified or Alternative placement within the Agency as available.The General Manager oversees the entire Workers’ Compensation Management Program and ensures the integrity of the program. This combined effort provides improved benefits to all Employees of the Agency, ensuring a prompt and healthy return to work after an injury or illness.

© 2004 Lynch & Associates/ Revision 1/2006 Page 7


OVERVIEW OF CALIFORNIA WORKERS’ COMPENSATION SYSTEM

The California workers’ compensation system is a “no fault” system. Injuries or illnesses that arise out of employment and occur in the course of employment are compensable in accordance with California law. In the event of a work-related injury or illness, the Employee must notify his or her employer as soon as possible. Injured Employees are protected from discrimination under California Labor Code Section 132(a). The workers’ compensation system was established and is closely monitored and controlled by the State of California. An employee does not require an attorney in order to receive benefits. If an employee chooses to retain an attorney, any fees for services rendered by the injured Employee’s attorney are deducted directly from the injured Employee’s benefits received through the workers’ compensation system.

This Agency is self-insured for workers’ compensation through the California Sanitation Risk Management Authority. Gregory B. Bragg & Associates, Inc. administers the Agency’s workers’ compensation to ensure that the injured Employee receives all applicable benefits in accordance with California Labor Code regulations. If you have questions about workers’ compensation, contact Bragg & Associates, or the Workers’ Compensation Coordinator (see Contact Information on the following page). If you are in need of further assistance, you may contact an Information and Assistance Officer at the nearest office of the State Division of Workers’ Compensation at (800) 736-7401. This information service is free.

The State of California’s workers’ compensation labor code laws govern the three parts of a workers’ compensation claim:

I. Medical TreatmentII. Compensation Payments for Lost WagesIII. Claim Resolution

I. Medical TreatmentThe State of California requires the Agency to provide all reasonable and necessary medical treatment to the injured Employee. The injured Employee pays no deductible and no co-payments. All costs are paid by the Agency through Bragg & Associates for the treating physician, prescriptions, hospital charges, lab fees, therapy, equipment such as crutches, back braces, etc., as well as the injured Employee’s mileage for such appointments. If the Agency has retained a Medical Provider Network (MPN), the Agency will direct injured Employees to a medical facility within the MPN, unless the Employee has pre-designated his/her personal physician in writing prior to the Date of Injury. If an injured Employee requires a change in physician, they can select one from the MPN or contact the Workers’ Compensation Coordinator for assistance. The injured Employee should make every effort to schedule follow up appointments, examinations and physical therapy to cause minimal impact on the workday. The number of physical therapy, occupational therapy, and/or chiropractic visits may be limited in accordance with California Labor Code laws; contact Gregory B. Bragg & Associates, Inc. for more information about treatment limitations. See your Workers’ Compensation Coordinator for the Agency’s current designated medical clinic. In the event of an emergency call 911.

II. Compensation PaymentsThe State of California requires the Agency to provide compensation to injured Employees who are disabled from work for a period of time due to a work-related injury/illness. If an Employee is unable to work for more than three days due to a work-related injury/illness, the Agency will provide the injured Employee with Total Temporary Disability payments (TTD) through the Third Party Administrator until one of the following occurs:

The treating physician releases the injured Employee back to his or her Usual & Customary position, or The injured Employee is offered a Transitional Assignment, or The injured Employee is offered a modification of the Usual & Customary position, or The Employee is determined to be permanently disabled from the Usual & Customary position.

Workers’ compensation will pay 2/3 of the injured Employee’s Average Weekly Wage up to the California State maximum, which changes based on the Date of Injury. In accordance with the California Labor Code, Total Temporary Disability payments will not be made for the first three days after the injured Employee leaves work unless the period of disability continues for more than 14 days or the Employee is hospitalized as an inpatient

In accordance with Labor Code Section 4600, a personal physician shall meet all of the following conditions: (A) The physician is the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (B) The physician is the employee's primary care physician and has previously directed the medical treatment of the employee, and who retains the employee's medical records, including his or her medical history. (C) The physician agrees to be pre-designated.


CSRMA: Workers’ Compensation Management ProgramInstruction Manualfor treatment required from the injury. Your Agency may also provide non-state-mandated benefits; contact the Workers’ Compensation Coordinator for information regarding the availability of additional benefits.



Overview of California Workers’ Compensation System (cont.)

Employees may not be compensated for absences from work due to medical or physical therapy appointments in accordance with the California Labor Code Section 4600 and the Agency’s policy, unless such appointments are requested by the Agency, the TPA, the Administrative Director, the Appeals Board, or a Workers' Compensation judge. Employees may use available accrued leave to cover lost time.

In the event of a work-related injury resulting in death, the Employee’s dependents would be eligible for benefits in accordance with the California Labor Code Section 4700-4709.

For questions regarding compensation, contact Bragg & Associates or the Workers’ Compensation Coordinator.

III. Claim ResolutionThe State of California guarantees that when medical treatment has brought the injured Employee to the point of maximum medical improvement and if the injury has resulted in permanent disability residuals (permanent restrictions given by the treating physician), the Agency is responsible for making a “permanent disability” payment to the injured Employee through the Third Party Administrator. The amount will be determined based on the percentage of disability and in accordance with the established amounts provided by the California Labor Code laws in compliance with workers’ compensation code. When permanent restrictions are given concerning the injured Employee, the Agency will engage in an interactive process with the injured Employee to determine if it is possible to offer a Modified Usual & Customary assignment or offer a new Alternative assignment to the Employee within the Agency. In accordance with the California Labor Code, a Modified position or Alternative position must provide at least 85% of the wages at the time of injury. If Modified or Alternative work is not available, then the injured Employee may be eligible for vocational rehabilitation benefits (Date of Injury prior to 1/1/04) or Supplemental Job Displacement Benefits (Date of Injury on or after 1/1/04).

CONTACT INFORMATION

NAME/TITLE TELEPHONEWorkers’ Compensation Coordinator

Third Party Administrator Gregory B. Bragg & Associates (800) 922-5020

Division of Workers’ Compensation Information & Assistance Officer (800) 736-7401

COMMON TERMS USED FOR WORKERS’ COMPENSATION

Date of Injury (DOI): The date that the alleged incident or exposure occurred. The date of injury in cases of occupational diseases or cumulative injuries is that date that the Employee first suffered disability and either knew, or in the exercise of reasonable diligence should have known, that the disability was work-related.

Employee’s Claim for Workers’ Compensation Benefits (DWC Form 1): Division of Workers’ Compensation (DWC) claim form, which is furnished by the Employer and completed by the Employee after an industrial injury.

Employee (EE): The injured Employee.

Employer (ER): The Agency.

Job Description: A description of the required tasks and physical demands of an Employee’s Usual & Customary position. A job description will be given to the Treating Physician for use during the Workers’ Compensation claim. Transitional Assignment (TA): A temporary assignment provided to an Employee to work during the recovery period of a work-related injury or illness.

Treating Physician (TX): The doctor primarily responsible for managing, monitoring, and reporting about the medical care and treatment of the injured Employee.


CSRMA: Workers’ Compensation Management ProgramInstruction ManualUsual & Customary position (U&C): The Employee’s regular job at the time of injury (not necessarily the activities performed while injury occurred).



WORKERS’ COMPENSATION MANAGEMENT FLOWCHART



CONTACT LIST

Driver Alliant Insurance Services600 Montgomery St., 9th Floor

San Francisco, CA 94111FAX: (415) 402-0773

JPA Manager:Dennis MulqueeneyDirect: (415) [email protected]

Assistant JPA Manager:Seth ColeDirect: (415) [email protected]

CSRMA Resources

www.csrma.org

Risk Control Advisor: David Patzer141 Sunnyglen Dr.Vallejo CA 94591(707) [email protected]

WC Advocate & Return to Work Specialist:

Heather TruroHT Consulting4142 Garatti Ct.Pleasanton CA 94566(925) [email protected]

Gregory B. Bragg and Associates, Inc. (Claims Administrator)

P.O. Box 619058Roseville, CA 95661-9058

Phone: (916) 783-0100Fax: (916) 783-4001

http://www.gbbragg.com

Primary Contact: Nancy Hutton Senior Claims Examiner(916) 960-0979

[email protected]

VP Workers Compensation Client Services:

Eileen Gould (916) [email protected]

Claims Supervisor: Lorri Lacey-Bogan (916) [email protected]

Claims Assistant:Kelsey Beam(916) [email protected]


http://www.gbbragg.com/


BEFORE AN INJURY HAPPENS:GETTING READY CHECKLIST

Workers’ Compensation Posting Notices (See page 17 in this manual for detailed instructions.) Is the notice current? Are there notices at all locations? Is the notice accurately filled out? (e.g., medical facility, claims administrator, contact information,

etc.) Is it readily viewable by employees?

New Hire Notification Requirements (See page 21 in this manual for detailed instructions.) Have all current employees been notified of their right to pre-designate a physician in case of a work-

related injury? Are all new employees being notified of their right to pre-designate a physician in case of a work-

related injury by the time of their first paycheck? Are you using the New Hire Packet included in this program in your new hire orientation for all new

employees?

Medical Provider Network (MPN)? (See page 24 in this manual for detailed instructions.) Have you notified all employees of their right to pre-designate a physician in case of a work-related

injury? Have you sent notification of the MPN to all employees? Do you have documentation of notification of the MPN for all employees? Do you know to which medical facilities you will be referring injured workers?

Online Claim Reporting Access (See page 34 in this manual for detailed instructions.) Have you requested online claim reporting access?

Preparation of the Documents/Forms for this program (See page 35 in this manual for detailed instructions.)

Have you printed the forms and documents needed for this program? Have you distributed the Declination of Medical Treatment and Initial Injury packets to the

Supervisors?

Job Descriptions (See page 36 in this manual for detailed instructions.) Make sure you have current and accurate job descriptions of all jobs or at least of those jobs that

employ the most people or are most likely to have occupational injuries.

OSHA log Requirements (See page 36 in this manual for detailed instructions.) Are you maintaining an OSHA 300 Log? Are you posting your completed OSHA 300 Log in accordance with OSHA requirements?

Injury and Illness Prevention Program (IIPP) (See page 40 in this manual for detailed instructions.) Do you have a written Injury and Illness Prevention Program (IIPP)? Do all of your employees know about the IIPP and know where to access a copy of the program? Are you conducting and documenting routine safety inspections? Are you conducting and documenting routine safety training for all employees?

Training Opportunities (See page 43 in this manual for detailed instructions.) Do you need or want any additional training on workers’ compensation or injury prevention? Do you know how to access free training and assistance through CSRMA’s website www.csrma.org? Do you know how to seek help from the CSRMA Risk Control Advisor at [email protected]? Do you know how to seek help from the CSRMA WC Claims Advocate and Return to Work Specialist at

[email protected]?

If the answer to any of these questions is NO, you may be subject to fines and penalties. Assistance is available to all CSRMA Member Agencies by contacting either:


mailto:[email protected]


http://www.csrma.org/


CSRMA Risk Control Advisor, David Patzer at [email protected] CSRMA WC Claims Advocate and Return to Work Specialist, Heather Truro at [email protected]





BEFORE AN INJURY HAPPENS:INTRODUCTION

Before an injury happens there are a number of things an employer must do to be in compliance with the laws and regulations, and to be adequately prepared to respond in an effective manner. Use this section of the Instruction Manual in conjunction with the Getting Ready Checklist on page 14 to ensure that your Agency is fully prepared for workers’ compensation claims before they happen.

This section of the instruction manual will help you in the following areas:

Workers’ Compensation Posting Notices

New Hire Notification Requirements

Medical Provider Network (MPN)

Online Claim Reporting Access

Preparing the Documents/Forms for this Program

Job Description Review Guidelines

OSHA Log Requirements (Maintenance & Posting)

Injury and Illness Prevention Program (IIPP)

Top Three Easiest OSHA Violations to Avoid

Training Opportunities



WORKERS’ COMPENSATION POSTING NOTICES:EXPLANATION

There are a variety of posting notices required of employers. For the purpose of this Workers’ Compensation Management Program, we will be addressing the two posting notices required by the California Division of Workers’ Compensation and Cal/OSHA.

1. Notice to Employees—Injuries Caused By Work2. Safety and Health Protection on the Job

California employers are required to post information about workers’ compensation so that it is easily viewable by all employees and in all locations. The information must be complete and current. Failure to follow these regulations can result in fines by Cal/OSHA and adversely impact the results of the employer’s workers’ compensation claims.

Notices can be obtained by accessing the following website at the California Department of Industrial Relations:

http://www.dir.ca.gov/WP.asp

If you need more than five copies of any posting notice, or have questions about required posting notices, email the California Department of Insurance at [email protected] or call (415) 703-5070. You may also fax an order to (415) 703-5074.

Samples of the two posting notices have been provided on the following two pages. The attached versions are the most current as of 12/5/05.




WORKERS’ COMPENSATION POSTING NOTICES:EXAMPLES

Copies of this notice can be obtained on the California

Department of Industrial Relations web site at:http://www.dir.ca.gov/WP.asp





Copies of this notice can be obtained on the California

Department of Industrial Relations web site at:http://www.dir.ca.gov/WP.asp





Copies of this notice can be obtained on the California Department of Industrial Relations web site at:






Copies of this notice can be obtained on the California Department of Industrial Relations web site at:





NEW HIRE NOTIFICATION REQUIREMENTS FOR WORKERS’ COMPENSATION:

EXPLANATION

There are numerous notifications required for newly hired employees. For further information on creating a comprehensive new hire training packet you may wish to refer to the CSRMA Guide to Recruiting, Interviewing and Hiring Essentials (Current revision 8/05). Section Y addresses new employee orientations. Alternatively you may wish to contact your Employment Law Counsel.

For the purposes of this Workers’ Compensation Management Program we have created a New Hire Packet, which should be included as part of your existing new employee orientation training. Please refer to the Workers’ Compensation Management Program New Hire Packet, which is included as a component of the overall program.

Personal Physician Pre-designationOne piece of the packet that has become even more critical as a result of the recent workers’ compensation reforms is the employer’s requirement to notify employees of their right to pre-designate a personal physician in case of a work-related injury. Labor Code Section 3551(a) requires employers to give every new employee, either at the time the employee is hired or by the end of the first pay period, written notice of this right.

You can use either the notice on the following page, or the notice included within the “Facts About Workers’ Compensation” pamphlet.

Now that CSRMA members have a State-approved Medical Provider Network (MPN), this notice becomes even more critical. Failure to notify employees of this right can result in penalties and or significant increases in workers’ compensation costs.


CSRMA: Workers’ Compensation Management ProgramPERSONAL PHYSICIAN PRE-DESIGNATION/

EMERGENCY CONTACT INFORMATIONEMPLOYEE:

DEPARTMENT:

DATE OF HIRE:

SUPERVISOR:

EMERGENCY CONTACT’S NAME:

EMERGENCY CONTACT’S RELATIONSHIP TO EMPLOYEE:

EMERGENCY CONTACT’S DAYTIME TELEPHONE:

EMERGENCY CONTACT’S EVENING TELEPHONE:

If you have a work-related injury during your employment with this Agency, you will be sent to our designated medical clinic. If you have an established relationship with a personal physician1, and you prefer to be sent to your physician for any work-related injuries in accordance with California Labor Code §4600, complete this form. Please note that the physician must be your primary care physician and agree to act in this capacity.Take the Pre-designated Physician Memo to your personal physician to read before signing this form in acceptance of the pre-designation status. Submit the completed form to the Workers’ Compensation Coordinator after you and your doctor have signed it. If you do not complete and return this form, you will be treated at the Agency’s designated medical clinic in the event of a work-related injury. If any of the information below changes at any time, please contact the Workers’ Compensation Coordinator immediately.

Check here for treatment at the Agency’s designated medical clinic.OR

Check here to pre-designate your personal physician. Be sure to:1. Provide the medical provider’s

current information, and2. Obtain the physician’s signature

below.

MEDICAL PROVIDER’S NAME:

ADDRESS:

PHONE NUMBER: MEDICAL SPECIALTY:

EMPLOYEE:I designate this physician to treat me in the event of a work-related injury during my employment with the Agency. This physician is my personal physician who has previously directed my medical treatment and who retains my medical records including my medical history. I understand that if necessitated by the nature of my injury or illness my employer may arrange appropriate first aid or emergency treatment before referring me to my personal physician.SIGNATURE:

DATE:

PHYSICIAN:I verify that I am this Employee’s personal physician in accordance with California Labor Code Section 4600 (see footnote below). I have read the Pre-designated Physician Memo and agree to accept this patient for treatment of any future work-related injuries or illnesses. I agree to comply with all State reporting requirements.SIGNATURE:

DATE:

If you have a personal chiropractor2 or acupuncturist3, you may chose to provide the information below in order to be eligible to change to this alternative physician during the course of a future workers’ compensation claim in accordance with California Labor Code §4601.

MEDICAL PROVIDER’S NAME: CHECK ONE: Chiropractor AcupuncturistADDRESS:

PHONE NUMBER:

Original: Workers’ Compensation CoordinatorCopy: Third Party Administrator

1 In accordance with Labor Code Section 4600, a personal physician shall meet all of the following conditions: (A) The physician is the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (B) The physician is the employee's primary care physician and has previously directed the medical treatment of the employee, and who retains the employee's medical records, including his or her medical history. (C) The physician agrees to be pre-designated.2 In accordance with Labor Code Section 4601, a personal chiropractor' means the employee's regular chiropractor licensed pursuant to Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code, who has previously directed treatment of the employee, and who retains the employee's chiropractic treatment records, including his or her chiropractic history.3 In accordance with Labor Code Section 4601 personal acupuncturist means the employee's regular acupuncturist licensed pursuant to Chapter 12 (commencing with Section 4935) of Division 2 of the Business and Professions Code, who has previously directed treatment of the employee, and who retains the employee's acupuncture treatment records, including his or her acupuncture history.



MEDICAL PROVIDER NETWORK (MPN):EXPLANATION

All CSRMA workers’ compensation pool members have the option to use the CSRMA Medical Provider Network (MPN) to provide treatment to employees with a work-related injury or illness.

What is the Medical Provider Network (MPN)?The MPN is a group of health care providers (physicians and other types of medical service providers) that the CSRMA Agencies use to treat employees injured on the job. The MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. The MPN must comply with all regulations according to the State of California Division of Workers’ Compensation.

Is my Agency utilizing the MPN Network?If your Agency has decided to utilize the MPN Network then an MPN Notification letter must be sent to every employee (and you must have receipt verification) 30 days prior to utilizing the MPN. If you have followed the notification process correctly then your Agency is participating in the MPN. For more detailed instruction on the MPN Notification process, see the Notification Requirements section immediately following this page.

Why should my Agency utilize the MPN?If your Agency utilizes the MPN (after proper notification procedures takes place) then you, the employer, can direct medical treatment for the life of the workers’ compensation claim. This is a method allowed by legislation to improve medical outcomes and decrease workers compensation costs. For more detailed instruction on the MPN notification process, see the Notification Requirements section immediately following this page.

How does the MPN work?If an employee gets injured on the job, their Agency will send them to see a doctor in the MPN for initial treatment. After the first visit, the employee can choose to continue to be treated by this doctor, or select another doctor from within the MPN. There are physicians and other medical service providers located throughout the state of California.

What if the injured employee disagrees with their MPN doctor?If the injured employee disagrees with the diagnosis or the treatment prescribed by their doctor, they are entitled to ask for a second opinion from another doctor within the MPN. If there is still a disagreement, the employee may choose to have a third opinion. If, after the third opinion, the employee still disagrees with their doctor, they can request an Independent Medical Review, which would be done by a doctor outside the MPN. Any opinions or reviews would be coordinated through the MPN Contact.

Who is the MPN Contact?The MPN Contact is a resource to provide answers to any questions or to provide assistance as needed:

Name: Professional Dynamics Inc.Title: MPN AdministratorAddress: P.O. Box 1090, Rancho Cordova CA 95741Telephone: (800) 591-5501Email: [email protected]

How can I learn more about the MPN process?CSRMA is offering the following training opportunities:

Area training in various sites around the state at the time of the kick-off of this program (March 2006)

Online training module via CSRMA web-site www.csrma.org




One-on-one training by request offered by Heather Truro, the CSRMA WC Advocate and Return to Work Specialist: [email protected], (925) 922-0305



MEDICAL PROVIDER NETWORK (MPN):NOTIFICATION REQUIREMENTS

In order to harness the benefits of the Medical Provider network (MPN), the first step* is for an employer to provide written notice (with proof of service) to all employees thirty (30) days prior to the beginning if the MPN usage. The recommended MPN notification document is included on the following seven pages.

CSRMA also strongly recommends sending the “Facts About Workers’ Compensation” Pamphlet with the MPN Notification letter. (Refer to the CSRMA Alert Bulletin dated January 2006.) For copies of the CWCI Facts About Workers Compensation pamphlet, contact the California Workers’ Compensation Institute at www.cwci.org, (510) 251-9470, or 1111 Broadway, Suite 2350, Oakland CA 94607

Once the MPN notice is provided, the employer selects one or more local facilities to provide services. Posting notices must be updated accordingly. To select an MPN facility, log on to http://www.professionaldynamics.com/. In many cases, this may be the same facility that is currently being used.

MPN Training OpportunitiesCSRMA is offering the following training opportunities:

Area training in various sites around the state at the time of the kick-off of this program (March 2006)

Online training module via CSRMA web-site www.csrma.org One-on-one training by request offered by Heather Truro, the CSRMA WC Advocate and Return

to Work Specialist: [email protected], (925) 922-0305

* For an MPN to work successfully, the employer must comply with the notification requirements for pre-designated physicians. Please refer to page 21 of this Instruction Manual to ensure all employees have been notified. If you are complying with the new hire notification requirement but cannot document that you have notified existing employees, we recommend that you do this prior to sending the MPN Notification. Some employers choose to send written notification of the right to pre-designate a personal physician with paychecks and with return receipt postage.


http://www.professionaldynamics.com/

http://www.cwci.org/

CSRMA California Sanitation Risk Management Authority

c/o DRIVER ALLIANT INSURANCE SERVICES, INC., an Alliant Resources Group Company600 Montgomery Street, 9th Floor San Francisco, CA 94111 ph: 415.403.1400Insurance License No.: 0C36861 fx: 415.402.0773

OFFICERS: PAST PRESIDENTS:Kevin Hardy, President Randy Musgraves760.438.3941 2002-2003Robert Reid, Vice President Jerry D. Smith408.378.2407 1998-2001

Today’s Date

Initial Written Employee Notification Re: Medical Provider Network (Title 8, California Code of Regulations, section 9767.12)

California Law requires your employer to provide and pay for medical treatment if you are injured at work. Your employer has chosen to provide this medical care by using a Workers’ Compensation physician network called a Medical Provider Network (MPN). The MPN for the California Sanitation Risk Management Authority, your employer’s workers’ compensation insurance provider, is administered by Interplan Health Inc. Your employer’s workers’ compensation claims administrator is Gregory Bragg and Associates. This notification is designed to tell you what you need to know about the operation of the MPN and describes your rights as an employee in choosing medical care for any on the job injuries or illnesses.

What is a Medical Provider Network?

A Medical Provider Network (MPN) is group of health care providers (physicians and other types of medical service providers) set up by an insurer or self-insured employer and approved by the Division of Workers’ Compensation’s Administrative Director to treat workers injured on the job. Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs must meet access to care standards for common occupational injuries and work-related illnesses. Further, the regulations require MPN providers to use medical treatment guidelines adopted by the DWC.

MPNs must allow employees a choice of provider(s) in the network after the employee’s first visit.

How do I find out which doctors are in the MPN?

Your employer has designated the following organization to be the MPN Contact for all employees: Name: Professional Dynamics Inc.Title: MPN AdministratorAddress: PO box 1090 Rancho Cordova CA 95741Telephone Number: (800) 591-5501Email address: [email protected]

A Joint Powers Authority

Important Information about Medical Care if you have a Work-Related Injury or Illness

This person will be able to answer your questions about the MPN and tell you how to receive or access the names of the doctors in the MPN.

A list of MPN providers can be obtained by calling our MPN contact person, by asking your employer or by visiting to the following website:www.professionaldynamics.com

In the event of an injury, the claims administration personnel at Gregory Bragg and Associates will be able to direct you appropriately.

CSRMA Initial Written Employee Notification Re: Medical Provider Network Page 28

1. This is the screen you will see when you go to www.professionaldynamics.com

2. You will see this screen pop up

Enter 6249 in the box and click “Submit”


Click on the link below “Interplan”


Click on “Provider Search”


Click on the type of provider you need and then click “Next”



What happens if I get injured at work?

In case of an emergency, you should call 911 or go to the closest emergency room.If you are injured at work, notify your employer as soon as possible. Your employer will provide you with a claim form. When you notify your employer or Gregory Bragg and Associates that you have had a work-related injury, your employer or Gregory Bragg and Associates will arrange an initial appointment with a doctor in the MPN.

How do I choose a provider?

After the first visit, you may continue to be treated by this doctor, or you may choose another doctor from the MPN. You may continue to choose doctors within the MPN for all of your medical care for this injury. If appropriate, you may choose a specialist, or ask your treating doctor for a referral to a specialist. If you need help in choosing a doctor, you may contact the MPN Contact listed above.

If you have trouble getting an appointment with a doctor within the MPN, contact the MPN Contact who will assist you.

What if there are no providers in my area?



Complete the requested information and then click “Search”

The MPN has providers for the entire state of California. Please visit www.professionaldynamics.com for a listing of providers in your area.

If you are temporarily working outside the MPN service areas, you may treat with a doctor outside of the MPN. If you are in a situation where a particular specialist is not available in your area, please contact the MPN Contact. You may have the right to see a specialist outside of the MPN in this case.

What if I disagree with my doctor about medical treatment?

If you disagree with your doctor, or do not like your doctor for any reason, you may always choose another doctor within the MPN.

If you disagree with either the diagnosis or treatment prescribed by your doctor, you may ask for a second opinion from a doctor within the MPN. If you want a second opinion, you must contact the MPN Contact and tell them you want a second opinion. The contact person will make sure you have a list of MPN doctors to choose from. Then you may choose a doctor from the MPN and make an appointment within 60 days. You must tell the MPN Contact person of your appointment date.

If you do not make an appointment within 60 days, you will not be allowed to have a second opinion with regard to this disputed diagnosis or treatment of this treating physician.

If the second opinion doctor feels that your injury is outside of the type of injury he or she normally treats, the doctor's office will notify your employer or insurer and you will get a new list of MPN doctors or specialists so you can make another selection.

After you receive a second opinion, if you still disagree with your doctor, you may ask for a third opinion. If you want a third opinion, you must contact the MPN Contact and tell them you want a third opinion. They will make sure you have a list of MPN doctors to choose from. Then you may choose a doctor from the MPN and make an appointment within 60 days. You must tell the MPN Contact of your appointment date.

If you do not make an appointment within 60 days, then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician.

If the third opinion doctor feels that your injury is outside of the type of injury he or she normally treats, the doctor's office will notify your employer or insurer and you will get a new list of MPN doctors or specialists so you can make another selection.

If after the third opinion, you still disagree with your doctor, you may ask for an Independent Medical Review (IMR). Your employer or MPN contact person will give you information on requesting an Independent Medical Review and a form at the time you request a third opinion.

An IMR will be done by a physician outside of the MPN who will be selected to conduct an independent assessment of your dispute.

As long as your second opinion, third opinion or Independent Medical Reviewer agrees with the treating doctor, you will need to continue to receive your medical treatment with doctors in the MPN network.

If the second opinion, third opinion or Independent Medical Reviewer does not agree with your treating doctor, you will be allowed to receive that medical treatment from a provider either inside or outside MPN. If you



decide to receive treatment outside the MPN, it can only be for the treatment or diagnostic service recommended by the second opinion, third opinion or Independent Medical Reviewer.

Once this treatment is completed, you will receive all other treatment with a doctor of your choice back in the MPN Network.

What if I am already being treated for a work-related injury before the starting date of the MPN? What is “transfer of care”?

Your employer has a “transfer of care” policy which describes what will happen if you are currently treating for a work-related injury with a physician who is not a member of the MPN.

If your current treating doctor is a member of the MPN, then you may continue to treat with this doctor.

If your current treating doctor is not a member of CSRMA’s MPN, then you may be sent to an MPN doctor for treatment. If this occurs, you will be sent a letter and your doctor will also be notified.

You will not be transferred to a doctor in the MPN if your injury or illness meets any of the following conditions:

(Acute) The treatment for your injury or illness will be completed within 30 days; (Serious or chronic) Your injury or illness is one that is serious and continues for at least 90 days

without full cure or worsens and requires ongoing treatment. You may be allowed to be treated by your current treating doctor for up to one year, until a safe transfer of care can be made.

(Terminal) You have an incurable illness or irreversible condition that islikely to cause death within one year or less.

(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date.

If the MPN is going to transfer your care and you disagree, you may ask your treating doctor for a report that addresses whether you are in one of the categories listed above.

If either MPN or you do not agree with your treating doctor's report, this dispute will be resolved according to Labor Code Section 4062. You must notify the MPN Contact listed previously if you disagree with this report.

If your treating doctor agrees that your condition does not meet one of those listed above, the transfer of care will go forward while you continue to disagree with the decision.

If your treating doctor believes that your condition does meet one of those listed above, you may continue to treat with him or her until the dispute is resolved.


What if I am being treated by an MPN doctor and that doctor leaves the MPN?

Your employer has a written Continuity of Care Policy that may allow you to continue treatment with your doctor if your doctor is no longer actively participating in the MPN.

If you are being treated for a work-related injury in the MPN and your doctor no longer has a contract with the MPN, your doctor may be allowed to continue to treat you if your injury or illness meets one of the following conditions:

(Acute) An Acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and or has a limited duration. Completion of treatment shall be provided for the duration of the acute condition.

(Serious Chronic) A serious chronic Condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the insurer or employer in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph shall not exceed 12 months from the contract termination date.

(Terminal) A terminal illness is an incurable or irreversible condition that has a high probability of causing death with one year or less. Completion of treatment shall be provided for the duration of the illness.

(Pending Surgery) Performance of a surgery or other procedure that is authorized by the insurer or employer as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contract’s termination date.

If any of the above conditions exist, the MPN may require your doctor to agree in writing to the same terms he or she agreed to when he or she was a provider in the MPN Network. If the doctor does not, he or she may not be able to continue to treat you.

If the contract with your doctor was terminated or not renewed by the MPN for reasons relating to medical disciplinary cause or reason, fraud or criminal activity, you will not be allowed to complete treatment with that doctor.

What if I have questions or need help?

MPN Contact: You may always contact the MPN Contact if you need more help or explanation about your medical treatment if you have a work-related injury or illness.

Name: Professional Dynamics Inc.Title:_MPN AdministratorAddress: PO box 1090 Rancho Cordova CA 95741Telephone Number: (800) 591-5501Email address: [email protected]

MPN website: WWW.Interplanhealth.com


DWC Information & Assistance Officer: If you have concerns, complaints or questions regarding the MPN, the notification process, or your medical treatment after a work-related injury or illness, you can call Information and Assistance Officer at the Division of Workers' Compensation at 1-800-736-7401.

Independent Medical Review: If you have questions about the Independent Medical Review process or the Independent Medical Reviewer, you may contact the Division of Workers’ Compensation’s Medical Unit at:

P.O. Box 8888San Francisco CA94128-8888(650) 737-2700 or (800) 794-6900


Keep this information in case you have a work-related injury or illness.


ONLINE CLAIM REPORTING ACCESS:INSTRUCTIONS TO REQUEST ACCESS

In order to be prepared when an injury occurs, it is important to request online claim reporting access before an injury happens to avoid delays in reporting. Access approval can take up to 72 hours.

Your Claims Administrator, Bragg & Associates, provides access to the online claim reporting system.

To sign up for access to complete the 5020 Employer’s Report of Injury or Illness online, go to http://www.gbbragg.com/5020. Bragg & Associates will notify you by email once the approval has been processed.

For instructions on how to report of claim (by completing the 5020 Employer’s Report of Occupational Injury or Illness) online, please refer to page 53, of this Instruction Manual.


http://www.gbbragg.com/5020


PREPARING DOCUMENTS/FORMS FOR THIS PROGRAM

Assembly: Instruction Manual: The Instruction Manual should be assembled in a 3-ring binder with sheet-protected pages. The final section of the Instruction Manual contains forms and letters, which can be photocopied for use. Electronic versions of the documents are also available in Microsoft Word (see “Electronic Documents” below on this page).

Workers’ Compensation Coordinator (WCC) Checklists: The Workers’ Compensation Coordinator has four checklists to use for reference in various workers’ compensation situations that may arise. Each checklist should be printed on a different color paper as a one-page double-sided document and then laminated. All four laminated checklists can be one-hole punched and held together with a single loose-leaf ring. The checklists are as follows:

Initial Response Checklist: For reference after initial notification of an injury or illnessReturn to Work Checklist: For reference after injured employees return from each doctor

visitStress Claim Checklist: For reference for all stress-related claimsInteractive Process Checklist: For reference after notification that an injured employee has

permanent restrictions.

Supervisor Checklist: The Supervisor Checklist should be printed on colored paper as a one-page double-sided document and then laminated. Each Supervisor should have a laminated Supervisor Checklist and a supply of Initial Injury Packets and Declination of Medical Treatment Packets.

Initial Injury Packets: The Initial Injury Packets should be assembled into 6” x 9” envelopes with the instructions printed on the front of the envelope. Include all of the Initial Injury Packet pages plus a DWC Form 1 “Employee’s Claim for Workers’ Compensation Benefits” in each envelope. The last two pages of the Initial Injury Packet should be printed on #10 envelopes before being included in the Initial Injury Packet envelope. All Supervisors/Departments must have access to a ready supply of Initial Injury Packets.

Declination of Medical Treatment Packets: The Declination of Medical Treatment Packets should be assembled in standard #10 envelopes with the instructions printed on the front. Include all of the pages of the Declination of Medical Treatment Packet in each envelope. All Supervisors must have access to a ready supply of Declination of Medical Treatment Packets.

Declination of Treatment Folder: The Declination of Treatment (DMT) folder will house any Declination of Treatment (DMT) forms that are completed by employees. Obtain a letter sized manila folder and label it as the Declination of Medical Treatment Folder. When you receive a completed DMT form, file it in the DMT Folder in date order.

New Hire Packets: The New Hire Packets should be assembled into 6” x 9” envelopes with the instructions printed on the front of the envelope. Include all of the New Hire Packet pages plus a “Facts for Injured Workers” pamphlet in each envelope. Packets should be supplied to whoever conducts your New Employee Orientation Training.

Reference Guide: The Reference Guide should be assembled in a 3-ring binder.

For Assistance:For assistance completing any of the procedures contained in this procedure manual, contact the CSRMA WC Advocate & Return to Work Specialist, Heather Truro at [email protected] or (925) 922-0305.

Electronic Documents:This entire program is also available in electronic format (Microsoft Word) via the CSRMA website: www.csrma.org. All documents are password protected so that only form fields can be edited. In order to see the form fields more easily, view the “FORMS” toolbar and click on the “FORM FIELD SHADING” icon. This will highlight all fields in gray.



OSHA LOG REQUIREMENTS:OSHA LOG MAINTENANCE: EXPLANATION AND REQUIREMENTS

Employers are required to maintain a log of occupational incidents/injuries, which is known as the OSHA 300 log. In 2002, OSHA replaced the OSHA 200 log with the current OSHA 300 log. Copies of the forms can be obtained on OSHA's web site at http://www.dir.ca.gov/dosh or from the OSHA publications office at (202) 693-1888.

The OSHA 300 log provides complete instructions on how to use, maintain, and post the log. The instructions that accompany the OSHA 300 Log contain examples of occupational injuries and the various types of occupational illnesses listed on the Log.

Please note there have been some recent changes, most notably the privacy concerns.

Privacy Concern Cases: The new rule at §1904.29(b)(6) through (10) requires the employer to protect the privacy of the injured or ill employee. The employer must not enter an employee's name on the OSHA 300 Log when recording a privacy case. The employer must keep a separate, confidential list of the case numbers and employee names, and provide it to the government upon request. If the work-related injury involves any of the following, it is to be treated as a privacy case (this is a complete list):

1. An injury or illness to an intimate body part or the reproductive system;

2. An injury or illness resulting from a sexual assault;3. A mental illness;4. HIV infection, hepatitis, or tuberculosis;5. Needle-stick and sharps injuries that are contaminated with another person's

blood or other potentially infectious material as defined by §1910.1030; or6. Other illnesses, if the employee independently and voluntarily requests that

his or her name not be entered on the OSHA 300 Log. (This does not apply to injuries. See the definition of "Injury and Illness" in §1904.46.)

For further explanation or to review frequently asked questions, please log on to the CAL/OSHA website at: http://www.dir.ca.gov/dosh, or contact David Patzer, CSRMA Risk Control Advisor at (707) 373-9709 or [email protected].


http://www.dir.ca.gov/dosh


OSHA 300 LOG REQUIREMENTS:OSHA LOG POSTING: EXPLANATION AND REQUIREMENTS

After the end of the year, employers must review the Log to verify its accuracy, summarize the 300 Log information on the 300A Summary form, and certify the summary (a company executive must sign the certification). This information must then be posted for three months, from February 1 to April 30. The employer must keep the records for five years following the calendar year covered by them.

If an employer has no recordable cases for the year, is an OSHA 300A Annual Summary still required to be completed, certified and posted?

Yes. After the end of the year, employers must review the Log to verify its accuracy, summarize the 300 Log information on the 300A summary form, and certify the summary (a company executive must sign the certification). This information must then be posted for three months, from February 1 to April 30.

If employers electronically post the OSHA 300A Summary of Work-related Injuries and Illnesses, are they in compliance with the posting requirements of 1904.32(b)(5)?

No. The recordkeeping rule allows all forms to be kept on computer equipment or at an alternate location, as long as the employer can produce the data when needed. Section 1904.32(b)(5), requires employers to post a copy of the Annual Summary in each establishment, where notices are normally posted [see 1903.2(a)], no later than February 1 of the year following the year covered by the records and kept in place until April 30. Only the OSHA 300A Summary form should be posted.

For further explanation, go to the Cal/OSHA website at: http://www.dir.ca.gov/dosh, or contact David Patzer, CSRMA Risk Control Advisor at (707) 373-9709 or [email protected].



OSHA LOG REQUIREMENTS:OSHA 300 LOG:

EXAMPLE

Copies of this form can be obtained on OSHA's web site at:http://www.dir.ca.gov/dosh

or from the OSHA publications office at:(202) 693-1888.




OSHA LOG REQUIREMENTS:OSHA 300A SUMMARY:

EXAMPLE

Copies of this form can be obtained on OSHA's web site at:http://www.dir.ca.gov/dosh

or from the OSHA publications office at:(202) 693-1888.




INJURY AND ILLNESS PREVENTION PROGRAM (IIPP):EXPLANATION & GUIDE FOR DEVELOPMENT

California Employers are required to create and implement a written Injury and Illness Prevention Program (IIPP). Failure to do so can result in significant fines and penalties. In addition to the compliance requirements, an effective IIPP is one of the most significant ways to protect your employees and reduce workers’ compensation costs. Why does Cal/OSHA require this? Because it works!

California Labor Code §3203. Injury and Illness Prevention Program:

(a) Effective July 1, 1991, every employer shall establish, implement and maintain an effective Injury and Illness Prevention Program (Program). The Program shall be in writing and, shall, at a minimum:

(1) Identify the person or persons with authority and responsibility for implementing the Program.

(2) Include a system for ensuring that employees comply with safe and healthy work practices. Substantial compliance with this provision includes recognition of employees who follow safe and healthful work practices, training and retraining programs, disciplinary actions, or any other such means that ensures employee compliance with safe and healthful work practices.

(3) Include a system for communicating with employees in a form readily understandable by all affected employees on matters relating to occupational safety and health, including provisions designed to encourage employees to inform the employer of hazards at the worksite without fear of reprisal. Substantial compliance with this provision includes meetings, training programs, posting, written communications, a system of anonymous notification by employees about hazards, labor/management safety and health committees, or any other means that ensures communication with employees.

Guide for Development of an IIPP:For assistance in creating an effective Injury and Illness Prevention Program (IIPP), access the Cal/OSHA website and refer to the Cal/OSHA Guide to IIPP Development: http://www.dir.ca.gov/dosh/dosh_publications/iipp.pdf


http://www.dir.ca.gov/dosh/dosh_publications/iipp.pdf


OTHER CAL/OSHA REQUIREMENTS:CHECKLIST

Establish, implement and maintain an Injury and Illness Prevention Program and update it periodically to keep employees safe.

Inspect workplace(s) to identify and correct unsafe and hazardous conditions.

Make sure employees have and use safe tools and equipment and properly maintain this equipment.

Use color codes, posters, labels or signs to warn employees of potential hazards.

Establish or update operating procedures and communicate them so employees follow safety and health requirements.

Provide medical examinations and training when required by Cal/OSHA standards.

Report immediately by telephone or fax to the nearest Cal/OSHA Enforcement Unit district office any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment as required by section 342(a), Title 8, California Code of Regulations (T8CCR). Serious injury or illness is defined in section 330(h), T8CCR.

Keep records of work-related injuries and illnesses, and post a copy of the totals from the last page of the 300 Log during the entire month of February each year, if the employer has 11 or more employees.

Post, at a prominent location within the workplace, the Cal/OSHA poster informing employees of their rights and responsibilities.

If required to keep one, provide employees, former employees and their representatives access to the Log and Summary of Occupational Injuries and Illnesses, Cal/OSHA form 300, at a reasonable time and in a reasonable manner.

Provide access to employee medical records and exposure records to employees or their authorized representatives.

Provide the Cal/OSHA enforcement personnel with names of authorized employee representatives who may be asked to accompany enforcement personnel during an inspection.

Do not discriminate against employees who exercise their rights under the California OSH Act.

Post Cal/OSHA citations at or near the work area involved. Each citation must remain posted until the violation has been corrected, or for three working days, whichever is longer. Post abatement verification documents or tags.

Correct cited violations by the deadline set in the Cal/OSHA citation and submit required abatement verification documentation.

Review Cal/OSHA website and free publications at http://www.dir.ca.gov/dosh.


http://www.dir.ca.gov/dosh/dosh_publications/shpstreng012000.pdf

http://www.dir.ca.gov/title8/3203.html


OTHER CAL/OSHA REQUIREMENTS:TOP THREE EASIEST OSHA VIOLATIONS TO AVOID

1. Not having proper posting notices:

If OSHA comes on to your site for any reason, they almost always look to see if notices have been posted in accordance with their regulations. Any one of the situations listed below can generate a penalty:

No notice, Notice is not current, Notice does not contain completed information about doctor/clinic & Claims Administrator, Notice is not readily visible, or Notices are not in each location.

A new penalty is cited for each location out of compliance. Refer to page 17 of this program for assistance in this area.

2. Not having a current or functional Injury & Illness Prevention Program (IIPP), or employees not being aware of it, or employees not knowing where to find a written copy.

OSHA Inspectors may ask Agency employees if they are familiar with, or can show them, a written copy of the IIPP. If an employee cannot respond in the affirmative, the Agency can be cited. Also please note that training is a component piece of an IIPP. If you have conducted training but cannot provide documentation, the Agency will be cited with penalties.

Refer to page 36 of this program for assistance in this area.

3. Not reporting a serious injury, illness or death immediately. Penalty: $5,000 minimum!

OSHA requires notification of a serious injury, illness or death immediately (but not later than 8 hours). Employers have been fined for waiting until the next business day to report these incidents. If 911 is called the paramedic or emergency personnel may alert OSHA; however, the employer still must make a call to OSHA as noted above.



JOB DESCRIPTION REVIEW GUIDELINES:JOB DESCRIPTION OVERVIEW

An injured Employee’s job description is one of the primary tools used in the workers’ compensation claim. The Treating Physician can use the job description to make an informed determination of the Employee’s ability to return to work, and the Supervisor and Workers’ Compensation Coordinator can use it to identify an appropriate Transitional Assignment. Since the ultimate goal of a Transitional Assignment is to return the Employee to his/her Usual & Customary position as soon as possible, then the immediate goal is to have the Employee perform as many Usual & Customary tasks as possible within the Transitional Assignment.

Job descriptions provide information needed by physicians to address the employee’s ability to return to work safely. Without a written job description, the physician is forced to make assumptions and will err on the side of caution. By having a well-written job description, it is much easier for the employer to find transitional work and return the employee swiftly and safely back to work.

Please review your current job descriptions to make sure they are: Current Accurate Meet at least minimum guidelines. (Please review the documents that follow to assist you in this

evaluation process.)

If your job descriptions do not meet the three preceding qualifications, CSRMA strongly encourages you to update your job descriptions using one of the following tools provided by CSRMA:

CSRMA Job Description Library : A collection of 30 different job descriptions in Microsoft Word format to be used off-the-shelf or with minor alterations

CSRMA Job Description Builder : A program using Microsoft Excel that allows you to create highly customized job descriptions. The Builder provides you with a set of departmental tasks, then you select the tasks specific to one position, and the Builder automatically provides the job-specific physical demands information.

CSRMA Member Agencies may access these online services through the CSRMA website at: www.csrma.org

Using a Job Description to create a transitional assignment for an injured Employee with restrictions:Use the “How to Review a Job Description” guidelines to review the Employee’s Usual & Customary position job description in order to determine which Usual & Customary essential functions, if any, an injured Employee can perform. Remember, it is possible that an Employee has restrictions, but is still able to perform all of the Usual & Customary position. Conversely, it is possible that certain restrictions preclude an Employee from performing the Usual & Customary position altogether.



JOB DESCRIPTION REVIEW GUIDELINES:HOW TO REVIEW A JOB DESCRIPTION

This guide is based on a basic job description format, but applies to all formats. Follow the instructions below when reviewing a job description to determine if an injured Employee is capable of performing some or all of the Usual & Customary position. Refer to the Employee’s abilities and/or restrictions as detailed on the most recent Employee Status Report while reviewing the job description.

Title Block: Confirm that the correct job description is being reviewed. Confirm number of hours per day and days per week reflect Employee’s work hours. Note date of preparation or last review to confirm that description is current to the best of

your knowledge.

Basic Function: Review overall description of job duties with Employee to confirm that this is correct job

description.

Essential Functions and Marginal Functions: Review each essential and marginal function with the Employee and note which functions

the Employee is unable to perform. If the Employee indicates inability to perform a certain function, refer to the Physical Demands section and confirm that the physical demands are outside of the Employee’s current physical abilities.

Briefly discuss any simple adjustments that could be made to enable the Employee to perform any of these tasks. For more assistance with this activity, contact the Workers’ Compensation Coordinator.

Physical Demands: As indicated above, refer to this section when evaluating the Employee’s ability to perform

certain functions. While each physical demand will not necessarily specify which functions it relates to, it is a useful guideline for determining the range of physical demands required.

Note that the core physical demands must add up to the total number of hours in the average workday. The core demands are sitting, standing, walking, kneeling, squatting/crouching, climbing, crawling and laying on back/stomach. The reason that they must total the number of average workday hours is that it is not possible to perform any two of these demands at the same exact time. This information can help you to evaluate the physical demands of a certain function in relation to the demands of the rest of the position.

Special Environment: Review this section if the Employee has a limited ability to work in certain environments.

Determine which functions are performed in an environment the Employee is restricted from in order to know which functions the Employee cannot perform.

Machines/Tools:

This section may be helpful for understanding the nature of certain functions. For example, if the Employee is currently unable to work with vibrating equipment, and a jackhammer is listed as one of the tools used, then it follows that the Employee would be unable to perform any functions requiring the use of a jackhammer.

Additional Requirements: This section may also be helpful for identifying circumstances that would preclude an

Employee from performing a certain function.



JOB DESCRIPTION REVIEW GUIDELINES:DEFINITIONS OF PHYSICAL DEMANDS

Standing: To be upright with the weight of the body on the feet without taking steps.

Walking: To take one or more steps at a time while upright.

Sitting: To be seated with the body supported by the buttocks and/or thighs.

Kneeling: To support some or all of the body’s weight on one or both knees.

Squatting: To support the weight of the body on the heels/toes, with the hindquarters close to the ground while knees are fully bent or nearly fully bent.

Crouching: To stoop or bend low and close to the ground with knees fully bent or nearly fully bent.

Crawling: To move with the weight of the body supported on the hand and knees. Often occurs in small or confined spaces.

Laying on Back/Stomach: To recline fully with the weight supported on either the back or front of the body.

Climbing: To ascend stairs, a step, a ladder, etc. This describes the motion of climbing ONLY, not balancing.

Balancing: To maintain a state of stability or equilibrium against unbalancing forces (e.g., standing in a moving vehicle, working on a roof, etc.)

Reaching: To extend one or both arms toward an object or piece of equipment or as a gesture.

Pushing: To exert force on an object, to move the object away from the force (e.g., sliding, shoving, kicking, etc.)

Pulling: To exert force on an object, to move it closer to the source of the force (e.g., tugging, dragging, etc.)

Twisting/Rotating: Waist : To turn at the body’s midsection. Neck : To turn at the neck. Generally to aid visually while performing tasks. Wrists/Forearms : To turn the wrists/forearms. Generally in conjunction with grasping.

Bending: Waist : To curve or otherwise move from the waist either forward, to one side, or backward. Neck : To curve or otherwise move from the neck either forward, to one side, or backward.

Generally to aid visually while performing tasks. Wrists/Forearms : To curve or otherwise move the wrists/forearms.

Lifting: To move or bring something upward from the ground or another surface.

Carrying: To move an object from one point to another by taking steps (not by pushing or pulling). Separate demand from lifting.

Gripping/Grasping: To hold an object by clasping with the hand(s) and fingers. May be simple grasping, which is the type required to handle something, although not necessarily while exerting force. May be power grasping which is the type required to manipulate most hand tools, or when applying force or pressure.


CSRMA: Workers’ Compensation Management ProgramInstruction ManualFine Manipulation: Includes pinching, picking, fingering or other tasks performed by the fingers, not the hands.



TRAINING AND EDUCATION:OVERVIEW

Training your staff about the CSRMA Workers’ Compensation Program is critical to its success. Our suggestions for training are as follows:

General ManagerThe General Manager should have a basic understanding of the program and its value and purpose. The General Manager should select a person on staff to function as the Workers’ Compensation Coordinator. The Workers’ Compensation Coordinator will take the lead in coordinating the necessary activities for the Agency and keep the General Manager informed of its progress. The General Manager can be trained along with the Managers and Supervisors as described below.

Workers’ Compensation Coordinator (WCC)The Workers’ Compensation Coordinator should read through all of the material provided in the program starting with this Instruction Manual and then each of the checklists and packets. The Reference Guide can be scanned and used as a resource on an as needed basis. The WCC can also seek supplementary training through the training modules offered on the CSRMA website www.csrma.org . Additional “jump start training can be provided by the CSRMA Workers’ Compensation Advocate and Return to Work Specialist, Heather Truro at [email protected] or (925) 922-0305. A training acknowledgement form is provided on page 49,and should be utilized to document that the training has been completed.

Supervisors and ManagersSupervisors and Managers should be trained when the Agency initiates the program. Refresher training should be completed annually and may be incorporated with other workplace safety training. The WCC can conduct or coordinate the training. Materials that should be included are: the New Hire Packet, the Initial Injury Packet, the Declination of Medical Treatment Packet, and the Supervisor Checklist. Training modules are offered on the CSRMA website www.csrma.org. A training acknowledgement form is provided on page 49, and should be utilized to document that the training has been completed.

EmployeesThe law requires California employers to train employees on workplace safety procedures, general knowledge about workers compensation and certain rights that they have under the California Labor Code and Rules and Regulations. Using the New Hire Packet at the time of hire is not only a good idea and important to this program, but it also helps employers meet many statutory obligations. Refresher training should be completed annually and may be incorporated with other workplace safety training. The WCC can conduct or coordinate the training. Materials that should be included are: the New Hire Packet, the Initial Injury Packet and the Declination of Medical Treatment Packet. Training modules are offered on the CSRMA website www.csrma.org. A training acknowledgement form is provided on page 49, and should be utilized to document that the training has been completed.







TRAINING AND EDUCATION:CSRMA WEB-BASED TRAINING MODULES

CSRMA has developed web-based training modules for ease of use and ready access for our members. There are two web-based training modules, which can be utilized by member agencies to train their Workers’ Compensation Coordinator, Supervisors and Employees on the Workers’ Compensation Management Program. Each training module takes approximately 45 minutes to complete.

The web-based training modules can be accessed via the CSRMA website at: www.csrma.org.

There are two web-based training modules, one for employees and the other for Supervisors and Workers’ Compensation Coordinators. Both modules cover the following:

Overview of Workers’ Compensation Coverage The Roles of the Various Players in the Workers’ Compensation Process Description of Injured Employee Benefits The Medical Provider Network Pre-designated Physicians Fraud The Workers’ Compensation Management Program What To Do in the Event of an Injury The Return to Work Process Claim Settlement

Additionally, the Supervisor/Workers’ Compensation Coordinator training module addresses:

CSRMA Claim Incidence The Supervisor’s Responsibilities The WCC’s Responsibilities The Employer’s Report of Occupational Injury or Illness Delayed Claims The Benefits of Transitional Assignments Potential Cost Savings The OSHA 300 Log Clinic Selection




TRAINING ACKNOWLEDGMENT

This Agency has implemented a comprehensive Workers’ Compensation Management Program in order to provide Employees with the opportunity to recover quickly, minimize wage loss and maintain a level of productivity after a work-related injury or illness. The program was developed through our Joint Powers Authority, the California Sanitation Risk Management Authority (CSRMA), which coordinates the Risk Management efforts of wastewater facilities throughout the State of California. This is an effective means to minimize workers’ compensation costs and provide improved benefits to all Employees.

The program is built on a team effort approach by all Employees, Supervisors, Department Managers, the Workers’ Compensation Coordinator, the General Manager and the Third Party Administrator as overseen by CSRMA. The active participation of all team players is necessary to achieve the goal of successfully returning injured Employees to work as healthy and productive members of the Agency.

By signing below, you are acknowledging that you have been fully trained in the Workers’ Compensation Management Program procedures and that you understand your responsibilities, and that you have received the CSRMA New Hire Packet.

We appreciate your cooperation.

ACKNOWLEDGMENTI have received the CSRMA New Hire Packet for the WC Management Program. I have completed the Workers’ Compensation Management Program training. I intend to follow the Workers’ Compensation Management Program procedures to the best of my ability for all claims.

NAME

TITLE

SIGNATURE DATE

TRAINED BY:

NAME:

SIGNATURE:

TRAINING DATE:

Original: Personnel File



WHEN AN INJURY OCCURS:OVERVIEW OF WORKERS’ COMPENSATION TOOLS

The previous section of the Instruction Manual addressed what needs to happen before an injury happens in order to be prepared when an injury happens. This section will address what to do when an injury occurs.

This Workers Compensation Management Program consists of the following components:

Instruction Manual New Hire Packet Reference Guide Declination of Medical Treatment (DMT) Packet Initial Injury Packet Supervisor Checklist Workers’ Compensation Coordinator (WCC) Checklists

The Instruction Manual provides you with everything you need to guide you through the set up and use of this program within your Agency. The New Hire Packet is utilized at the time a new Employee is hired. The Reference Guide provides you with additional valuable information to help you on an as needed basis.

The remainder of the components are tools to assist you in a very streamlined manner so that when an injury occurs, you will not have to flip through binders trying to remember what to do:

The responsibilities and instructions for the Supervisors are spelled out in a step-by-step manner on the Supervisor Checklist.

As indicated on the Supervisor Checklist, the Supervisor will provide either the Declination of Injury Packet or the Initial Injury Packet to the injured Employee. The Supervisor will assist the Employee with completion of the paperwork. The Employee will return from the doctor with the completed Employee Status Report (ESR) and provide it to the Workers’ Compensation Coordinator (WCC).

The Workers’ Compensation Coordinator (WCC) Checklists help the WCC with his/her responsibilities in all steps of the process. The most commonly used checklists will be the Initial Injury Response and the Return to Work Process checklists. Even though the circumstances are rare, there are WCC Checklists for Stress Claim Procedures and the Interactive Process. Although they may not be used often, you will be glad to have them should these situations occur.

As you work through these processes, there may be references to specific forms, letters and guidelines. These are contained in Section V of this Instruction Manual (starting on page 57).

For further illustration of how the workers’ compensation management process works, refer to page 12 of this Instruction Manual to review a flowchart of the process.



WHEN AN INJURY OCCURS:OVERVIEW OF ROLES AND RESPONSIBILITIES

The workers’ compensation process involves a team of people working toward the common goal of helping the injured worker recover and return to productive work. The following summarizes the key responsibilities of each party:

The Employee: The employee is trained through the New Hire Packet and in subsequent Injury and Illness Prevention Program (IIPP) training that they are expected to report all injuries immediately to their Supervisor. If the employer, however, becomes aware of an injury, then the employer has a duty to respond. Therefore, even if the employee fails in their duty to report an injury, you must still direct medical care and follow the procedures as noted on the Supervisor and Workers’ Compensation Coordinator Checklists. The employee will need to bring completed Employee Status Reports (ESRs) from the doctor to the WCC.

The Supervisor: The Supervisor should follow the steps listed on the Supervisor Checklist. H/She will have provided the employee with either the Declination of Injury Packet or the Initial Injury Packet. The Supervisor will assist the employee with completion of the paperwork and refer him/her to the appropriate medical facility.

The Workers’ Compensation Coordinator (WCC): The WCC will help advise the Supervisor and/or the Employee of the appropriate medical facility for initial treatment. The WCC will make sure the Supervisor has completed their responsibilities on the checklist, keep in contact with the injured Employee and assist in identifying return to work possibilities. The WCC will follow the WCC Injury Response Checklist and continue with the WCC Return to Work Checklist until the injured Employee returns to full duty. The WCC will seek assistance from the resources provided by CSRMA as needed and as directed on the checklists. The WCC will maintain contact with the Third Party Administrator, Bragg and Associates, through the conclusion of the claim to ensure the best possible result. The WCC will follow the Stress Claim Checklist if the circumstances warrant. The WCC will follow the Interactive Process Checklist if it is determined that the injured Employee has permanent work restrictions.

The remainder of this section provides additional detailed information for those who may need it on how to complete the DWC-1 Claim Form (included in the Initial Injury Packet) and the 5020, Employers Report of Occupational Injury or Illness.



WHEN AN INJURY OCCURS:HOW TO COMPLETE THE DWC-1 FORM

1. The authorized employer representative must complete the bottom employer section before giving or mailing the form to the employee.

a) Do not fill in line 13 until the employee returns the form.b) Fill in lines 9, 10, 14, 15, 17 & 18.c) Fill in line 11 with the date when the employer first knew of the injury/illness.d) Fill in line 12 with the date that the claim form was given or mailed to employee.

The form should not be given out in advance.e) Sign the form on line 16 after filling out the form.

2. Tear off and keep a copy as your temporary receipt. Mail a copy of the temporary receipt to Gregory B. Bragg & Associates if the injured employee does not fill out the form on that day.

3. If the injured employee is not present, you must mail the form to him/her. If the injured employee is present, give the partially completed form to him/her with the instruction to fill out the top Employee section.

4. Within 24 hours of receiving this form back from the injured worker:a) Fill in line 13 with the date that the form was received from the employee.b) Give a completed copy to the employee.c) Within 24 hours, mail a completed copy to Bragg & Associates .

By completing this form you are not admitting liability, but simply complying with the law. Failure to provide this form within 24 hours of knowledge of an injury could result in a $100 fine. Failure to provide this form within 24 hours of request could result in a $5,000 fine.


THE DWC-1 FORM MUST BE PROVIDED TO THE INJURED WORKER WITHIN 24 HOURS OF ANY KNOWLEDGE OF INJURY/ILLNESS


WHEN AN INJURY OCCURS:ONLINE 5020 INSTRUCTIONS

To submit an electronic 5020 “Employer’s Report of Occupational Injury or Illness,” you will need a user name and password for Bragg & Associates’ website. If you need a user name and/or password, register at http://gbbragg.com/5020. Follow the steps below to complete the 5020 form online:

1. Go to the Bragg & Associates website at http://www.gbbragg.com.

2. Click on “Online CA 5020” link.

3. Click on the “Electronic 5020 Log In” link.

4. Enter in your username and password.This link will open up Adobe Acrobat Reader. Once the Acrobat Reader is open, the 5020 form will open in your browser window. The information supplied to Bragg & Associates from your initial signup form will be filled in automatically.

5. Click in the appropriate boxes to begin entering information. You may press the tab key to navigate between fields.

Note: Date fields need to be entered in mm/dd/yyyy format. Phone numbers and the Social Security Number will format automatically, so please enter the numbers without dashes or parentheses. Also, please input only numeric data in time fields, e.g. 6:30 AM should be entered as 0630.

If you don’t know certain information, please leave the field blank, do not enter “n/a” or unknown.

6. Once you have completed data entry on the form, select File | Print from the menu to print the form.

7. Please sign the form and include it with the documents to fax and mail to Bragg & Associates.

8. After printing, click the Submit button. This function uploads the information into Bragg & Associates’ claim system, and notifies your claim team that you have submitted a report of injury.

9. When the submit function is completed, you will see an acknowledgement screen, which gives you the claim number assigned for the report of injury.

10. You will also receive an acknowledgement via e-mail that your report has been successfully submitted.

If you have any problems with the online 5020, contact technical support via email at [email protected] or telephone at (800) 422-7244.

NOTE: Initial Online access can take about 48-72 hours to be approved. If you are filing a claim for the first time and have not already acquired online access, use a copy of the 5020 form provided on page 55, and call Bragg & Associates at (800) 922-5020 to notify them that you will be sending the 5020 by fax. Please identify yourself as a member of CSRMA to expedite assistance.


http://www.gbbragg.com/


WHEN AN INJURY OCCURS:ADDITIONAL INSTRUCTIONS FOR COMPLETING THE 5020 FORM

The authorized employer representative must fill out the form as completely as possible. A report must be filed as soon as possible after any knowledge of an occupational injury/illness. The online 5020 is the most efficient method to report a claim. Studies have shown the faster a claim is reported, the better the outcome. Here are detailed instructions for completing the form:

a) Questions 7 through 16 are for injured employee information. It is important that you include the injured employee’s name, home address, social security number, date of birth, date of hire, employee status (permanent, temporary, volunteer), earnings, hourly rate and number of hours worked per week.

b) Questions 17 through 26 are for date of injury information. It is important that you include the date of injury, time the injury occurred, the dates the injured employee left work and returned, or if the injured employee is still off work.

c) Question 17 is the same date that appears on line 11 of the DWC-1 form: “Date employer first knew of injury”

d) Question 18 is the same date that appears on line 12 of the DWC-1 form: “Date claim form was provided to employee”

e) Questions 19 through 29A request specific information regarding the injury and the treatment that was sought. Each of these lines on the form has an example that will help you make your explanation just as specific.

f) Question 38: provide current gross wages/salary (for efficiency, please attach a wage statement/payroll log if possible).

g) If any of these questions cannot be answered, write “unknown” in the blank.


State of CaliforniaEMPLOYER’S REPORTOF OCCUPATIONALINJURY OR ILLNESS

Please complete in triplicate (type if possible). Mail two copies to: OSHA CASE NO.

FATALITY

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony

California law requires employers to report within five days of knowledge every occupational injury or illness, which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

EMPLOYER

1. FIRM NAME 1a. Policy Number PLEASE DO NOTUSE THISCOLUMN

2. MAILING ADDRESS (Number and Street, City, Zip) 2a. Phone NumberCASE NUMBER

3. LOCATION IF DIFFERENT FROM MAILING ADDRESS (Number and Street, City, Zip) 3a. Location CodeOWNERSHIP

4. NATURE OF BUSINESS; e.g. Painting contractor, wholesale grocer, sawmill, hotel, etc. 5. State Unemployment Insurance Acct. #

6. TYPE OF EMPLOYER:

Private State County City School Dist Other Government - Specify

INDUSTRY

INJURY

OR

ILLNESS

7. DATE OF INJURY / ONSET OF ILLNESS

(mm/dd/yy) 8. TIME INJURY/ILLNESS OCCURRED

a.m. p.m.9. TIME EMPLOYEE BEGAN WORK

a.m. p.m.10. IF EMPLOYEE DIED, DATE OF DEATH(mm/dd/yy)

OCCUPATION11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY?

YES NO

12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK,

CHECK THIS BOX:

15. PAID FULL DAY’S WAGES FOR DATE OF INJURY OR LAST DAY WORKED?

YES NO

16. SALARY BEING CONTINUED?

YES NO17. DATE OF EMPLOYER’S KNOWLEDGE/NOTICE OF INJURY (mm/dd/yy)

18. DATE EMPLOYEE WAS PROVIDED EMPLOYEE CLAIM FORM (mm/dd/yy)

SEX

19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS, if available, e.g. second degree burns on right arm, tendonitis on left elbow, lead poisoning.

AGE

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) 20a. COUNTY 21. ON EMPLOYER’S PREMISES? DAILY HOURS

YES NO22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping Department, Machine Shop.

YES NO DAYS PER WEEK

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene welding torch, farm tractor, scaffold.

WEEKLY HOURS

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck.WEEKLY WAGE

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS, e.g. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld and burned right hand. USE SEPARATE SHEET IF NECESSARY.

COUNTY

27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip) 27a. PHONE NUMBER NATURE OF INJURY

28. HOSPITALIZED AS INPATIENT OVERNIGHT NO YES If yes then, NAME AND ADDRESS OF HOSPITAL (Number, Street, City, Zip)

28a. PHONE NUMBERPART OF BODY

29. EMPLOYEE TREATED IN EMERGENCY ROOM?

YES NOATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29(b)(6)-(10) & 14300.35(b)(2)(E)2.Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*

SOURCE

EMPLOYEE

30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm/dd/yy) EVENT

33. HOME ADDRESS (Number, Street, City, Zip) 33a. PHONE NUMBERSECONDARY

SOURCE34. SEX 35. OCCUPATION (Regular job title - NO initials, abbreviations or numbers) 36. DATE OF HIRE (mm/dd/yy)

MALE FEMALE

37. EMPLOYEE USUALLY WORKS 37a. EMPLOYMENT STATUS 37b. UNDER WHAT CLASS CODE OF YOUR POLICY WERE WAGES ASSIGNED?

hours per day days per week total weekly hours

regular, full-time part-time

temporary seasonal

EXTENT OF INJURY

38. GROSS WAGES/SALARY:

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, $ per

Completed by (type or print) Signature & Title Date (mm/dd/yy)

*Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers’ compensation or other insurance claim, and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and federal workplace safety agencies.

FORM 5020 (Rev7) June 2002 FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY


NEW CLAIM INFORMATION COVERSHEET

TODAY’S DATE:

# OF PAGES:

TO: TPA:Bragg & Associates

FROM: WORKERS’ COMP. COORD.:

ADDRESS:P.O. Box 619058

AGENCY:

Roseville, CA 95661 TELEPHONE #:

TELEPHONE #:(800) 922-5020

FAX:

FAX #:(916) 783-4001

EMAIL:

URGENTPlease send acknowledgment within 48 hours.

EMPLOYEE’S NAME:

INCIDENT DATE:

DOCUMENTSATTACHED TO FOLLOW

DWC-1 Employee’s Claim for Workers’ Compensation Benefits (Insurer/Claims Administrator Copy)

5020 Employer’s Report of Occupational Injury or Illness (signed original)

Incident/Accident Report (copy)

PLEASE CONSIDER FURTHER INVESTIGATION ON THIS CLAIM (IF BOX IS CHECKED)

COMMENTS:

CONFIDENTIALITY NOTICE: This message is intended only for the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited, and you are requested to please notify us immediately by telephone, and discard this message forthwith. We truly appreciate your cooperation.

Original: Fax & Mail to Claims Examiner, Third Party AdministratorCopy w/attachments: CSRMA Risk Control Advisor


CSRMA: Workers’ Compensation Management ProgramINSTRUCTION MANUAL

NOTES PAGEEMPLOYEE:

TELEPHONE:

JOB TITLE:

DATE OF INJURY:

DEPARTMENT:

SUPERVISOR:

CLAIMS EXAMINER:

TELEPHONE:

DATE ACTIVITY/ACTION

Original: Employee’s Workers’ Compensation File



EMPLOYEE WAGE STATEMENTIn response to the Third Party Administrator’s request for a statement of the indicated Employee’s wages for the 52 weeks prior to the Date of Injury, either complete this form, or attach a printout of the applicable payroll data.

EMPLOYEE:

DATE OF INJURY:

WAGES: $ per

JOB TITLE:

DATE FROM

DATE TO

REGULAR HOURS & WAGES

OTHOURS & WAGES

DATE FROM

DATE TO

REGULAR HOURS & WAGES

OTHOURS & WAGES

1 27

2 28

3 29

4 30

5 31

6 32

7 33

8 34

9 35

10 3

6

11 3

7

12 3

8

13 3

9

14 4

0

15 4

1

16 4

2

17 4

3

18 4

4

1 4


CSRMA: Workers’ Compensation Management ProgramINSTRUCTION MANUAL9 520 4

6

21 4

7

22 4

8

23 4

9

24 5

0

25 5

1

26 5

2

I certify that the above is a true copy of the Employee’s payroll earnings as shown on the Employer’s records.NAME: TITLE: SIGNATURE: DATE:

Original: Workers’ Compensation Coordinator

WCC: Forward original to Claims ExaminerFile a copy in the Employee’s workers’ compensation file



WORK ABILITIES MEMOTO: PHYSICIAN:

FROM: WORKERS’ COMP. COORD.:

MEDICAL CENTER:

AGENCY:

FAX #:

TELEPHONE #:

TODAY’S DATE:

# OF PAGES:

FAX #:

URGENTPlease fax response within 4 hours.

EMPLOYEE’S NAME:

INCIDENT DATE:

This Employee has returned from a medical appointment and either:1. The Treating Physician did not complete the customized Employee Status Report, or2. The Employee is Totally Temporarily Disabled

I am attempting to determine if there is an appropriate Transitional Assignment for the Employee considering his/her work abilities. Please follow the instructions after the checked box below: (WCC check one box)

1. The information provided on your work status slip regarding the Employee’s restrictions is not sufficient to address Return to Work:Please complete the attached Employee Status Report so that I may fully understand your determination regarding the Employee’s work abilities in accordance with Labor Code Section 3762 (c). Fax your response to me at the fax number above, and to our Third Party Administrator at (916) 783-4001. If you refuse to complete this form or otherwise clarify the Employee’s work abilities, please complete the bottom portion of this page and return it to me via fax as soon as possible. In that case, our Third Party Administrator will contact you for further information. I am unwilling to complete the Employee Status Report at this time due to the following:

SIGNATURE OF PHYSICIAN OR AUTHORIZED STAFF MEMBER: PRINT NAME & TITLE:

2. You have indicated that the Employee is Totally Temporarily Disabled:I believe that there may be work available that is of a comparable level of activity to the Employee’s activities of daily living. Please complete the section below so that I may better understand the Employee’s physical capabilities.

ACTIVITIES OF DAILY LIVING: Check each item that the Employee is able to perform Light housekeeping

(tidying, wiping kitchen counters, etc.) Child care

Age of children): Personal grooming (bathing, dressing,

etc.) Washing dishes

Driving personal vehicle Vacuuming Grocery shopping Outdoor gardening Hobbies/sports (fishing, golf, etc.)

Describe: Other:

PHYSICIAN’S SIGNATURE:

DATE:

Contact me at the number above if you have any questions regarding this request. Thank you.© 2004 Lynch & Associates/ Revision 1/2006 Page 61


GUIDELINES FOR WHEN TO SEND THE WORK ABILITIES MEMO

The Work Abilities Memo is a tool to be used in any of the following situations:

When a physician does not use the CSRMA Employee Status Report

When the physician is vague in his/her description of what the employee can or cannot do

When the physician indicates total temporary disability with no reasonable explanation

When you think the employee should be able to do more than what the doctor has indicated (e.g., If the doctor just writes: “no lifting”—that would essentially be describing a complete invalid. No lifting would mean the person could not lift his/her clothes to dress him/herself, could not lift a utensil to feed him/herself.)

When you think an employee’s restrictions might be to keep him or her from “overdoing it.” If working the full job description, but limiting it to four hours per day or three days per week, is doable you may want to let the doctor know you can accommodate those kinds of shifts on a temporary basis.



EMPLOYEE STATUS REPORTCONFIDENTIAL INFORMATION

EMPLOYEE NAME:

DATE OF INJURY:

APPOINTMENT DATE:

TIME IN:

DATE OF BIRTH:

DEPARTMENT:

TIME OUT:

EMPLOYER:(Name, Address, Telephone)

NEXT APPOINTMENT DATE:

INJURY TYPE: Recordable First Aid

“Yes, I have reviewed the Employee’s Usual & Customary job description prior to addressing work status.”

INJURY/TREATMENT WORK STATUSTYPE OF INJURY:

A. RELEASED TO USUAL & CUSTOMARY ON (Date):

PHYSICAL THERAPY:

sessions per week for weeks

B. RELEASED TO RESTRICTED DUTY ON (Date):

C. TOTAL TEMPORARY DISABILITY EFFECTIVE (Date): SURGERY SCHEDULED?:

NO YES, DATE: ANTICIPATED DATE OF MAXIMUM MEDICAL IMPROVEMENT:

WORK ABILITIESMaximum hours Employee can perform each activity per day

No restriction

6 hours

4 hours

2 hours

1 hour

0 hours COMMENTS

Sitting Standing/Walking Squatting Kneeling/Crawling Climbing Bending Twisting Pushing/Pulling Weight limitations: HAND/ARM USE:Reaching Fine Manipulation Keyboard/Mouse Use Simple Grasping Power Grasping LIFTING/ CARRYING:0-10 lbs. 11-25 lbs. 26-50 lbs. 50+ lbs. Can Employee work entire shift? Yes No If no, how many hours? Can Employee work overtime? Yes No If yes, how many hours? Does Employee need periodic rest breaks? Yes No If yes, how often? Can Employee operate/work around moving equipment? Yes No Can Employee operate a vehicle/forklift/heavy equipment? Yes No Can Employee operate vibrating equipment (jack hammer, etc.)? Yes No Can Employee wear a respirator? Yes No Can Employee enter/work in confined spaces? Yes No Can Employee work at heights? Yes No Is Employee on any medication that affects work ability? Yes No If yes, explain:

PHYSICIAN INFORMATIONI declare under penalty of perjury that to the best of my information and belief I have not violated California Labor Code Section 139.3 and have not offered, delivered, received or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration for any referral for examination or evaluation by a physician.NAME:

SIGNATURE:

DATE:

TELEPHONE:

FAX:

E-MAIL:

PHYSICIAN: Give completed original to Employee to return to Workers’ Compensation CoordinatorAND fax to Gregory B. Bragg & Associates, Inc. at (916) 783-4001 AND Workers’ Compensation Coordinator at



TREATING PHYSICIAN COMMUNICATION GUIDELINES

If more information is necessary in order to determine the Employee’s work status, contact the Treating Physician’s office by telephone and use this form as a guide to obtaining the necessary information.

Release Of Information:If the Treating Physician’s office is reluctant to give you information regarding the Employee, advise them that as the Employer you may have access to this information to address Return to Work issues. If the physician is concerned about sharing information that may be available to the Employer, refer to Labor Code Section 3762 (c) which does allow for the release of the following medical information to the employer:

1) Medical information limited to the diagnosis of the mental or physical condition for which workers’ compensation is claimed and the treatment provided for this condition,

2) Medical information regarding the injury for which workers’ compensation is claimed that is necessary for the employer to have in order for the employer to modify the employee’s work duties.

Also explain that according to the United States Department of Health & Human Services Office for Civil Rights, the HIPAA Privacy Rule permits covered entities to disclose protected health information to workers’ compensation insurers, State administrators, employers, and other persons or entities involved in workers’ compensation systems, without the individual’s authorization. (45 CFR §164.512)

Advise the Treating Physician that you are requesting detailed information in order to “modify the Employee’s work duties.” Inform the Treating Physician that you are trying to uphold the Agency’s Return to Work Policy, which provides Employees with an appropriate Transitional Assignment if possible when they are unable to return to Usual & Customary work immediately.

Acceptable Questions:The following questions are examples of acceptable questions in accordance with the California Labor Code (see above):

Did you receive and review the Employee’s Usual & Customary Job Description? Which Usual & Customary job tasks can the Employee perform? What are the Employee’s work restrictions? What activities is the Employee capable of performing either at work or at home? What is the maximum weight the Employee is capable of lifting? At what level? What “light duty” or “transitional tasks” can the Employee perform? Is the Employee on any medication that would prevent him/her from being able to operate a

vehicle, or to operate or work around moving equipment or machinery? When do you expect the Employee to return to his/her Usual & Customary position? When do you expect the Employee to be able to perform a Transitional Assignment? Do you believe the Employee’s current transitional assignment has been aiding his/her recovery?

Stress-related claims additional questions:

Does the Employee have physical restrictions? If so, what activities can the Employee perform?

What temporary changes to the Employee’s physical work environment could be made so that the Employee could return to work? (e.g. improved lighting, temperature adjustment, noise level adjustment, different workspace, etc.)

Are there any other temporary changes that would make it possible for the Employee to return to work? (e.g., such as changing Supervisor, department or shift)

Further Action/ Assistance:If the Treating Physician still will not provide the necessary information, notify the Claims Examiner to take further action.


CSRMA: Workers’ Compensation Management ProgramINSTRUCTION MANUALFor further Assistance: Contact CSRMA’s Return to Work Specialist, Heather Truro at HT Consulting (925) 922-0305



TRANSITIONAL TASK MATRIX

This Transitional Task Matrix was developed by Vallejo Sanitation and Flood Control District, and is provided here as a reference for identifying transitional tasks in your Agency. Some of the tasks may not correspond exactly with the tasks in your Agency’s departments.

DEPT BACK INJURIES(limited lifting & bending)

ARM, WRIST, & SHOULDER INJURIES(restricted use of one extremity)

LEG, KNEE, & ANKLE INJURIES(limited time on feet)

Admin/Fin/Safety

Answer front phones Bank deposit Binding Papers Data entry – training & MSDS database Dust furniture, window sills, desks, cabinets,

etc. throughout plant Filing, get records ready for scanning Follow-up telephone calls on trouble-calls Making copies of forms Making new file folders and labels Posting safety information on bulletin boards Preview safety videos pertaining to job Sanitize countertops Sorting Mail Getting vehicles washed, fueling

Answer front phones Bank deposit Binding Papers Data entry – training & MSDS database Dust furniture, window sills, desks,

cabinets, etc. throughout plant Filing, get records ready for scanning Follow-up telephone calls on

trouble-calls Making copies of forms Making new file folders and labels Posting safety information on

bulletin boards Preview safety videos pertaining to

job Sanitize countertops Sorting Mail Getting vehicles washed fueling

Answer front phones Bank deposit Binding Papers Data entry – training & MSDS database Dust furniture, window sills, desks,

cabinets, etc. throughout plant Filing, get records ready for scanning Follow-up telephone calls on

trouble-calls Making copies of forms Making new file folders and labels Posting safety information on

bulletin boards Preview safety videos pertaining to job Sanitize countertops Sorting Mail Getting vehicles washed, fueling

Engineering Answer front phones Binding Papers Calculate sewer connection fees Data entry Data entry – training & MSDS database

(sfty) Distribute flyers for upcoming meeting

construction projects District cleanout address gathering Dust furniture, window sills, desks, cabinets,

etc. throughout plant File as-built copies in FOPS Filing, paperwork of inspections Follow-up telephone calls on trouble-calls

Answer front phones Calculate sewer connection fees Data entry – training & MSDS

database (sfty) Distribute flyers for upcoming meeting

construction projects District cleanout address gathering Dust furniture, window sills, desks,

cabinets, etc. throughout plant File as-built copies in FOPS Filing, paperwork of inspections Follow-up telephone calls on

trouble-calls Labeling storm drains

Answer front phones Binding Papers Calculate sewer connection fees Data entry Data entry – training & MSDS

database (sfty) Distribute flyers for upcoming meeting

construction projects District cleanout address gathering Dust furniture, window sills, desks,

cabinets, etc. throughout plant File as-built copies in FOPS Filing, paperwork of inspections Follow-up telephone calls on

CSRMA Workers’ Compensation Management programVSFCD Transitional Task Matrix Page 66

Eng (cont’d) Labeling storm drains Making copies of forms (sfty) Making new file folders and labels (sfty) New as-builts to be filed, need copying in

some cases Observe construction jobs Organize & File Drawings Posting safety information on bulletin boards Preview safety videos pertaining to job Purge unneeded sheets from newer as-builts Sanitize countertops Unroll plans and compare if we already have

them in the as-built data base Update various data bases Washing Eng. Vehicles, fueling

Making copies of forms (sfty) Making new file folders and labels

(sfty) New as-builts to be filed, need

copying in some cases Observe construction jobs Organize & File Drawings Posting safety information on


job Purge unneeded sheets from newer

as-builts Sanitize countertops Unroll plans and compare if we

already have them in the as-built data base

Update various data bases Washing Eng. Vehicles, fueling Weeding around plant/pump

stations

trouble-calls Labeling storm drains Making copies of forms (sfty) Making new file folders and

labels (sfty) New as-builts to be filed, need

copying in some cases Observe construction jobs Organize & File Drawings Posting safety information on

bulletin boards Preview safety videos pertaining to job Purge unneeded sheets from newer

as-builts Sanitize countertops Unroll plans and compare if we already

have them in the as-built data base Update various data bases Washing Eng. Vehicles, fueling Weeding around plant/pump stations

Field Operations

FOPS

Add work orders into computer Answer front phones Assist with map updates – drive by and

confirm updates Basin Map Work Catch basin visual inspections Computer entry Data entry – training & MSDS database (sfty) District cleanout address gathering Dust furniture, window sills, desks, cabinets,

etc. throughout plant Entering upper lateral info into Hansen Follow-up telephone calls on trouble-calls Haul debris Identify physical existence of fixed assets

from report Incomplete work order cleanup Inventory work bays Labeling storm drains Load & Unload Ops Truck Making copies of forms (sfty)

Add work orders into computer Answer front phones Assist with map updates – drive by and

confirm updates Basin Map Work Calif. Native Plant Nursery Work Catch basin visual inspections Computer entry Data entry – training & MSDS

database (sfty) District cleanout address gathering Dust furniture, window sills, desks,

cabinets, etc. throughout plant Entering upper lateral info into Hansen Follow-up telephone calls on

trouble-calls Haul debris Identify physical existence of

fixed assets from report Incomplete work order cleanup Inventory work bays

Add work orders into computer Answer front phones Assist with map updates – drive by

and confirm updates Basin Map Work Calif. Native Plant Nursery Work Catch basin visual inspections Computer entry Data entry – training & MSDS

database (sfty) District cleanout address gathering Dump trash can in bay Dust furniture, window sills, desks,

cabinets, etc. throughout plant Entering upper lateral info into Hansen Follow-up telephone calls on

trouble-calls Haul debris Identify physical existence of fixed assets

from report Incomplete work order cleanup


(cont’d) Making new file folders and labels (sfty) Manhole inspections Organizing parts and tools Outline sub-basins on map book pages Posting safety information on bulletin boards Preview safety videos pertaining to job Sanitize countertops Subdivision TV Tape Review Sweeping around yard Wash vehicles inside & out Writing in easement books – updated

addresses

Labeling storm drains Load & Unload Ops Truck Making copies of forms (sfty) Making new file folders and

labels (sfty) Manhole inspections Organizing parts and tools Outline sub-basins on map book pages Posting safety information on

bulletin boards Preview safety videos pertaining to job Sanitize countertops Subdivision TV Tape Review Sweeping around yard Wash vehicles inside & out Weeding around plant/pump stations Writing in easement books – updated

addresses

Inventory work bays Labeling storm drains Load & Unload Ops Truck Making copies of forms (sfty) Making new file folders and

labels (sfty) Manhole inspections Organizing parts and tools Outline sub-basins on map book pages Posting safety information on

bulletin boards Preview safety videos pertaining to job Sanitize countertops Subdivision TV Tape Review Sweeping around yard Wash vehicles inside & out Weeding around plant/pump stations Writing in easement books – updated

addresses

Maintenance

Maintenanc

Answer front phones Check/change burned out indicator

lights on all equipment (i.e. run, on, off, alarm lights)

Clean Shop Data entry – training & MSDS database

(sfty) Dust furniture, window sills, desks, cabinets,

etc. throughout plantFollow-up telephone calls on trouble-calls Hosing around plant Identify physical existence of fixed assets

from report Inspect tools for defects Labeling Equipment Labeling storm drains Making copies of forms (sfty) Making new file folders and labels (sfty) Order parts for jobs Organize spare parts in both shops

Answer front phones Calif. Native Plant Nursery Work Check/change burned out indicator


Clean Shop Data entry – training & MSDS

database (sfty) Dust furniture, window sills, desks,

cabinets, etc. throughout plant Follow-up telephone calls on

trouble-calls Hosing around plant Identify physical existence of fixed

assets from report Inspect tools for defects Labeling Equipment Labeling storm drains Making copies of forms (sfty) Making new file folders and



Clean Shop Data entry – training & MSDS

database (sfty) Follow-up telephone calls on


assets from report Inspect tools for defects Labeling Equipment Labeling storm drains Making copies of forms (sfty) Making new file folders and

labels (sfty) Order parts for jobs


e(cont’d)

Posting safety information on bulletin boards Preview safety videos pertaining to job Safety Inspections Sanitize countertops Take vehicles for oil changes Update maintenance manuals Updating construction drawings Wash trucks/golf carts Writing in easement books – updated

addresses Writing/issuing work orders

labels (sfty) Order parts for jobs Organize spare parts in both shops Posting safety information on

bulletin boards Preview safety videos pertaining to job Safety Inspections Sanitize countertops Take vehicles for oil changes Update maintenance manuals Updating construction drawings Wash trucks/golf carts Weeding around plant/pump stations Writing in easement books – updated


Organize spare parts in both shops Posting safety information on

bulletin boards Preview safety videos pertaining to job Safety Inspections Sanitize countertops Take vehicles for oil changes Update maintenance manuals Updating construction drawings Wash trucks/golf carts Weeding around plant/pump stations Writing in easement books – updated


Operations

Operations

Answer front phones Check/change burned out indicator


Data entry – training & MSDS database (sfty)

Dust furniture, window sills, desks, cabinets, etc. throughout plant

Filling out spreadsheets in Ops Follow-up telephone calls on trouble-calls Hosing around plant Identify physical existence of fixed assets

from report Labeling Equipment Making copies of forms (sfty) Making new file folders and labels (sfty) Monitor computers & gates Posting safety information on bulletin boards


lights on all equipment (i.e. run, on,

off, alarm lights) Data entry – training & MSDS

database (sfty) Dust furniture, window sills, desks,

cabinets, etc. throughout plant Filling out spreadsheets in Ops Follow-up telephone calls on


assets from report Labeling Equipment Making copies of forms (sfty)



Data entry – training & MSDSdatabase (sfty)

Filling out spreadsheets in Ops Follow-up telephone calls on trouble-calls Hosing around plant Identify physical existence of fixed

assets from report Labeling Equipment Making copies of forms (sfty) Making new file folders and

labels (sfty) Monitor computers & gates Posting safety information on


(cont’d) Preview safety videos pertaining to job Record equipment run counters for plant

equipment for future troubleshooting Safety Inspections Sanitize countertops Updating construction drawings Washing sludge trucks Writing in easement books – updated

addresses Writing/issuing/closing out work orders

Making new file folders and labels (sfty)

Monitor computers & gates Posting safety information on


job Record equipment run counters for

plant equipment for future troubleshooting

Safety Inspections Sanitize countertops Updating construction drawings Weeding around plant/pump

stations Writing in easement books –

updated addresses

Writing/issuing/closing out work orders

bulletin boards Preview safety videos pertaining to job Record equipment run counters for

plant equipment for future troubleshooting

Safety Inspections Sanitize countertops Updating construction drawings Washing sludge trucks Weeding around plant/pump stations Writing in easement books – updated

addresses Writing/issuing/closing out work orders

Environ. Services (lab & PCD)

Answer front phones Attend Safety Comm. Meeting Checking Mailboxes & Faxes Data entry – training & MSDS database (sfty) Data Entry into computer (pcd) Distributing Lab Equipment (lab) Drive-By Inspections (pcd) Dust furniture, window sills, desks, cabinets,

etc. throughout plant Field Screenings of catch basins Follow-up telephone calls on trouble-calls Inspect Vehicles Labeling equipment/labware

cabinets (lab) Labeling storm drains Making copies of forms (sfty) Making media for microbiology

tasks (lab) Making new file folders and labels (sfty) Monthly Safety Inspection Organize labware glasses (lab) Organizing PCD files

Answer front phones Attend Safety Comm. Meeting Calif. Native Plant Nursery Work Checking Mailboxes & Faxes Data entry – training & MSDS

database (sfty) Data Entry into computer (pcd) Distributing Lab Equipment (lab) Drive-By Inspections (pcd) Dust furniture, window sills, desks,

cabinets, etc. throughout plant Field Screenings of catch basins Follow-up telephone calls on

trouble-calls Inspect Vehicles Labeling equipment/labware

cabinets (lab) Labeling storm drains Making copies of forms (sfty) Making media for microbiology

tasks (lab) Making new file folders and

Answer front phones Attend Safety Comm. Meeting Calif. Native Plant Nursery Work Checking Mailboxes & Faxes Data entry – training & MSDS

database (sfty) Data Entry into computer (pcd) Distributing Lab Equipment (lab) Drive-By Inspections (pcd) Field Screenings of catch basins Follow-up telephone calls on trouble-

calls Inspect Vehicles Labeling equipment/labware cabinets

(lab) Labeling storm drains Making copies of forms (sfty) Making media for microbiology

tasks (lab) Making new file folders and

labels (sfty) Monthly Safety Inspection


ES (cont’d)

Posting safety information on bulletin boards Preview safety videos pertaining to job Sanitize countertops Testing Water and solids samples (lab) Wash Vehicles & Fueling Washing Equipment (lab) Writing in easement books – updated

addresses

labels (sfty) Monthly Safety Inspection Organize labware glasses (lab) Organizing PCD files Posting safety information on


job Sanitize countertops Testing Water and solids samples

(lab) Wash Vehicles & Fueling Washing Equipment (lab) Writing in easement books –

updated addresses

Organize labware glasses (lab) Organizing PCD files Posting safety information on

bulletin boards Preview safety videos pertaining to job Sanitize countertops Testing Water and solids samples (lab) Wash Vehicles & fueling Writing in easement books – updated

addresses



TRANSITIONAL ASSIGNMENT DESCRIPTION FORM

EMPLOYEE:

DEPARTMENT:

U&C JOB TITLE:

SUPERVISOR:

DATE OF INJURY:

TEMPORARY SUPERVISOR (if applicable):

TEMPORARY WORK LOCATION (if applicable):

TEMPORARY SCHEDULE:

TRANSITIONAL ASSIGNMENT JOB DUTIES Dr. if EE can

performTASK 1: Physical Demands*: TASK 2: Physical Demands*: TASK 3: Physical Demands*: TASK 4: Physical Demands*: TASK 5: Physical Demands*: TASK 6: Physical Demands*:

PHYSICAL DEMANDSThe hour breakdown of physical demands is as follows: (May be a range of hours)

SITTING: PUSHING/PULLING (MAXIMUM WEIGHT/FORCE): STANDING/WALKING:

KNEELING/ SQUATTING: LIFTING (MAXIMUM WEIGHT): CRAWLING:

CLIMBING: OTHER: TOTAL MAJOR PHYSICAL DEMAND HOURS:

*In addition to physical demands, indicate any knowledge, skills or abilities required to perform the task.Note to WCC: If the Treating Physician has not indicated specific restrictions for the Employee, you may choose to complete this form with very light tasks and then send it to the Treating Physician for approval.

PHYSICIAN USE ONLY (Physician check

one):

Employee is released to perform the above tasks on:Employee is not released to perform the above tasks, due to the following

reason(s):

but Employee will be reevaluated for this assignment on: .PHYSICIAN NAME:

SIGNATURE:

DATE:

FAX COMPLETED FORM TO:



TRANSITIONAL ASSIGNMENT AGREEMENT

EMPLOYEE:

DEPARTMENT:

DATE OF INJURY:

TODAY’S DATE:

TREATING PHYSICIAN: BRIEF DESCRIPTION OF INJURY (e.g. sprained right wrist, dislocated left shoulder, etc.): WORK RESTRICTIONS:

CURRENT ASSIGNMENT: Modified Usual & CustomaryDescribe Temporary Modification:

See Attached Transitional Assignment Description FormTRANSITIONAL ASSIGNMENT WORK SCHEDULE:

START DATE:

END DATE*:

* The assignment End Date is the next medical appointment date or two weeks from the Start Date whichever is sooner.

Transitional Assignments are intended to assist in the Employee’s recovery until medical restrictions change, or until the assignment is completed, or as otherwise determined by the Agency.

At the end of this Transitional Assignment, the Agency will engage in an interactive process with the Employee to determine whether or not a new Transitional Assignment can be assigned based on the Employee’s physical restrictions and the availability of transitional work.

All Agency personnel rules and regulations apply during the Transitional Assignment.

We, the undersigned participated in a meeting with the others indicated below in order to determine an appropriate Transitional Assignment for the Employee. In order to prevent further injury or aggravation to the Employee’s present condition, we agree that the Employee will work within the work restrictions prescribed by the Treating Physician. If any party is aware that the Employee is working outside of these restrictions, they will immediately inform the Workers’ Compensation Coordinator of the situation.

IF PRESENT AT

MEETING SIGNATURE DATEINJURED EMPLOYEE: U&C SUPERVISOR: TRANSITIONAL ASSIGNMENT SUPERVISOR: WORKERS’ COMPENSATION COORDINATOR:



OTHER:

Original: Workers’ Compensation CoordinatorCopy w/attachment: U&C Supervisor

Transitional Assignment Supervisor (if applicable)Employee

WCC: Forward Copy to Claims Examiner w/attachment



TWO-WEEK TRANSITIONAL ASSIGNMENT REVIEW

EMPLOYEE:

U&C POSITION TITLE:

DATE OF INJURY:

DEPARTMENT:

INJURY:

SUPERVISOR:

1. Is the Employee still working in the Transitional Assignment?Comments:

YES NO

2. Is the Transitional Assignment still available?Comments:

YES NO

3. Is the Transitional Assignment productive for the Department/Agency?Comments:

YES NO

4. Has the Employee been working to an acceptable standard of productivity?Comments:

YES NO

5. Does the Employee consistently work within physical restrictions?Comments:

YES NO

6. Does the Employee work without excessive supervision?Comments:

YES NO

7. Is the Employee receiving adequate supervision?Comments:

YES NO

8. Are there any personnel issues that are affecting the Transitional Assignment (tardiness, excessive absences, etc.)Comments:

YES NO

9. Is the Employee’s subjective experience (perception of pain, recovery likelihood, etc.) consistent with the Treating Physician’s objective findings (medical determination)?Comments:

YES NO

After answering all of the questions on the worksheet, determine whether it would be beneficial to continue the current Transitional Assignment or to identify a new assignment.

If the answers to most of questions are “yes,” then it is probably beneficial to extend the Transitional Assignment. If the answers to most of the questions are “no,” then it is probably beneficial to identify a new Transitional Assignment.

Remember that these decisions must be made on a case-by-case basis. In individual cases, one of the questions above may outweigh the rest, so it is important to weigh the questions appropriately.

DETERMINATION: Continue Current Transitional Assignment Conclude Transitional Assignment.

WORKERS’ COMPENSATION COORDINATOR:

DATE:

Original: Workers’ Compensation Coordinator



TELEPHONE CONTACT FORM & GUIDEWorkers’ Compensation Coordinator: Use this form to track telephone calls with Employees who are Totally Temporarily Disabled (TTD). Contact should be made every two weeks. The purpose is to maintain positive contact with the employee and to assist his/her recovery. This will keep you updated on their progress and offer assistance to them in case there are any stumbling blocks to their recovery (such as delays in treatment, lack of communication with the doctor, etc.) This telephone call also gives the Employee the opportunity request a call from the Third Party Administrator for answers to his/her questions about the workers’ compensation claim.

EMPLOYEE:

TELEPHONE #:

DEPARTMENT:

DATE OF INJURY:

SUPERVISOR:

INJURY TYPE:

The tone of this call should be professional, positive and friendly. Let the Employee know that you care about their recovery and that you can help them to get answers to any questions they have regarding their claim. For example: “Hello. I am calling to check in to see how you are doing concerning your injury. Have you seen the doctor lately? And what does the doctor say about your recovery? When are you going back to the doctor? Would you like the Third Party Administrator to contact you to answer any questions?”

CALL#

DATE OF CONTACT

CALL

IF LEFT

A MESSAGE

WHEN WAS YOUR LAST MEDICAL

VISIT?

ARE YOU STILL TOTALLY

TEMPORARILY DISABLED?

WHEN DOES THE DOCTOR THINK YOU

WILL RETURN TO WORK?

WHEN IS YOUR NEXT DOCTOR’S

VISIT?

DO YOU WANT

THE TPA TO CALL

YOU?FOLLOW

UP ITEMS?

1 2 3 4 5 6 7 8 9

10 11 12

Original: Keep in Employee’s workers’ compensation file


TREATING PHYSICIAN MEMO: STRESS RELATED CLAIM

TO: Treating Physician

FROM: NAME

TITLE

Re: INJURED EMPLOYEE:

An Employee of ours has been seen in your office for treatment of a condition that may be work-related. S/he has indicated that job-related stress may have caused or contributed to a need for medical or psychological treatment. I am attempting to determine if there is a return to work possibility for this Employee.Please complete the enclosed Employee Status Report so that I may understand the nature and extent of the condition in order to determine the Employee’s ability to return to work at this time. Enclosed is the job description of the injured Employee’s duties, which you should review prior to making a determination regarding work status. Please fax the completed Employee Status Report to me at (Fax Number) and then mail the original to me at (Address) .We have instituted a Workers’ Compensation Management Program and will attempt to modify the current position or place the Employee into a Transitional Assignment if necessary. Please note that Labor Code Section 3762 (c) does allow for the release of the following medical information to the employer:

1) Medical information limited to the diagnosis of the mental or physical condition for which workers’ compensation is claimed and the treatment provided for this condition,

2) Medical information regarding the injury for which workers’ compensation is claimed that is necessary for the employer to have in order for the employer to modify the employee’s work duties.

Also note that according to the United States Department of Health & Human Services Office for Civil Rights, the HIPAA Privacy Rule permits covered entities to disclose protected health information to workers’ compensation insurers, State administrators, employers, and other persons or entities involved in workers’ compensation systems, without the individual’s authorization. (45 CFR §164.512)

Should you have any questions or need to review additional information, please contact me by telephone at (Telephone Number) . Thank you for your full cooperation.

encl: Employee Status ReportUsual & Customary Job DescriptionReturn Envelope

c: Claims Examiner, Third Party Administrator

© 2004 Lynch & Associates/ Revision 1/2006 Print on Agency Letterhead


EMPLOYEE STATUS REPORT:CONFIDENTIAL INFORMATION STRESS RELATED CLAIM

EMPLOYEE:

DATE OF VISIT:

DATE OF INJURY:

NEXT APPOINTMENT DATE:

AGENCY:

CLAIM NUMBER:

WORK STATUS:Check appropriate box and enter date

RELEASED TO USUAL & CUSTOMARYDATE OF RETURN:

TOTALLY TEMPORARILY DISABLED*EXPECTED DATE OF RETURN:

*IF EMPLOYEE IS TTD, WHAT SPECIFICALLY PRECLUDES HIM/HER FROM WORK?

RELEASED WITH RECOMMENDATIONS DETAILED BELOWDATE OF RETURN:

At this time, do your medical findings indicate that the Employee’s "physical work environment" could be altered to allow the employee to remain/return to transitional duty? If yes, How so?

Yes No

At this time, do your medical findings indicate that a change in "interpersonal relationships" at the Employee’s workplace could allow the employee to remain/return to transitional duty? If yes, How so?

Yes No

Was there an accident or injury related to the onset of this stress related condition? If so, please describe:

Yes No

Is the Employee able to have contact with the public? Yes No

Psychological treatment to continue for a period of: Medical treatment to continue for a period of: Recommended temporary changes to the "physical work environment" in order to return Employee to work:

Other recommended temporary changes in order to return Employee to work:

PHYSICIAN’S NAME:

TELEPHONE:

SIGNATURE:

DATE:

FAX:

I declare under penalty of perjury that to the best of my information and belief I have not violated California Labor Code Section 139.3 and have not offered, delivered, received or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration for any referral for examination or evaluation by a physician.

Fax completed form to: Mail the original to:



INTERACTIVE PROCESS:Complete a separate worksheet for each possible position. ACCOMMODATION WORKSHEET

EMPLOYEE NAME:

MEETING DATE:

POSITION TITLE:

DEPARTMENT:

RESTRICTIONS:

AGENCY:

CHECK ONE: Usual & Customary Position Alternative Position

A:

Essential Functions: fundamental job duties of the position; activities that individual in this position must perform (list below or attach job description)

Marginal Functions: non-essential job duties; activities that may need to be performed but not necessarily by every individual in this position (list below or attach job description)

B: Possible Accommodations Cost (if any) Source (if any)

1. 2. 3. 4.

C: Check here if the Job Accommodation Network was consulted: Accommodations discussed:

D:

Selected Accommodation(s)

MEETING PARTICIPANTS: Each participant must print name and initial below to indicate participation in the Interactive ProcessTITLE:

NAME:

INITIAL: TITLE:

NAME:

INITIAL:

EMPLOYEE:

INITIAL: DEPARTMENT HEAD:

INITIAL:



Original: Workers’ Compensation Coordinator/Employee’s File


JOB OPPORTUNITIES LETTER

(Date)

(Employee’s Name)(Employee’s Address)(Employee’s City/State/Zip Code)

Dear (First Name):

Because your physician has determined that you are permanently disabled and unable to return to your regular job assignment within the Agency I have been working to identify an appropriate modified or alternate position for you. We were unable to identify an appropriate modification of your Usual & Customary position that would accommodate your restrictions; therefore, we are extending the search to all available positions within the Agency.

Enclosed please find a list of jobs that are currently available. Please review the list and indicate on the enclosed form the jobs, if any, that you may be qualified for, and that you may be able to perform with or without accommodation within your medical limitations as indicated by your Treating Physician. If you are not sure whether or not you may be able to perform the position within your medical limitations, please include it on enclosed form.

Please return the completed Job Opportunities Response Form to me within 3 days. I will then contact you to arrange a time that we can meet to discuss the job opportunities. According to California workers’ compensation laws, the Agency has a very limited time to make a job offer to you. If an appropriate position cannot be identified by (Date) , you may be eligible for Vocational Rehabilitation (date of injury prior to 1/1/04) or Supplemental Job Displacement Benefits (date of injury on or after 1/1/04).

Please contact me at if you have any questions.

Sincerely,

(Name)(Title)

encl: Job Opportunities Response Form Return Envelope

c: Claims ExaminerHuman Resources Department (if any)


CSRMA: Workers’ Compensation Management ProgramWORKERS’ COMPENSATION COORDINATOR PROCEDURES

JOB OPPORTUNITIES RESPONSE FORM

EMPLOYEE:

DATE OF INJURY:

Please review the list of positions that are currently available throughout the Agency. In the space below, indicate which jobs, if any, you may be qualified for. Please sign the completed form in the space provided and return it within 3 days using the enclosed envelope.

FIRST PREFERENCEJob Title: Department:

SECOND PREFERENCEJob Title: Department:

THIRD PREFERENCEJob Title: Department:

Check this box if you do not believe you are qualified for any of the available job positions.

EMPLOYEE’S SIGNATURE:

DATE:

Return completed and signed form within 3 days to: NAME: TITLE: AGENCY: ADDRESS:


NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK(For dates of injury prior to 1/1/04 only)

THIS SECTION COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR:Employer (name of firm) is offering you the position of a (name of job) . Attach a list of the duties required of the position.You may contact concerning this offer. Phone No.: Date of offer: Date job starts: Claims Administrator: Claim Number:

NOTICE TO EMPLOYEE Name of employee: Date offer received:

You have 30 calendar days from receipt to accept or reject this offer of modified or alternative work. If you reject this job offer, you will not be entitled to rehabilitation services unless:

Modified Work

A. The proposed modification(s) to accommodate required work restrictions are inadequate.B. The modified job will not last 12 months.

Alternative Work

A. You cannot perform the essential functions of the job: orB. The job is not a regular position lasting at least 12 months; orC. Wages and compensation offered were less than 85% paid at the time of injury; orD. The job is beyond a reasonable commuting distance from residence at time of injury.THIS SECTION TO BE COMPLETED BY EMPLOYEE

I accept this offer of Modified or Alternative work. I reject this offer of Modified or Alternative work and understand that I am not entitled to vocational rehabilitation services.

Date Signature

I feel I cannot accept this offer because:

NOTICE TO THE PARTIES

If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.

The employer or claims administrator must forward a completed copy of this agreement to the Rehabilitation Unit with a Notice of Termination (DWC Form RU-105) within 30 days of acceptance or rejection.

If a dispute occurs regarding the above offer or agreement, either party may request the Rehabilitation Unit to resolve the dispute by filing a Request for Dispute Resolution (DWC Form RU-103) at the applicable Rehabilitation Unit. The Rehabilitation Unit venue is the same as the Workers’ Compensation Appeals Board. If no WCAB case exists, file with a Rehabilitation Unit at the appropriate district office.

MANDATORY FORMATSTATE OF CALIFORNIA

DWC-RU-94 (1/03) §10133.12

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK(For injuries occurring on or after 1/1/04)

THIS SECTION COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR:Employer (name of firm) is offering you the position of a (name of job) . You may contact concerning this offer. Phone No.: Date of offer: Date job starts: Claims Administrator: Claim Number:

NOTICE TO EMPLOYEE Name of employee:

Date of Injury: Date offer received:

You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless:

Modified Work or Alternative Work

A. You cannot perform the essential functions of the job; orB. The job is not a regular position lasting at least 12 months; orC. Wages and compensation offered are less than 85% paid at the time of injury; orD. The job is beyond a reasonable commuting distance from residence at time of injury.THIS SECTION TO BE COMPLETED BY EMPLOYEE

I accept this offer of Modified or Alternative work. I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement Benefit.

I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job Displacement Benefit.

Date Signature

I feel I cannot accept this offer because:

NOTICE TO THE PARTIES

If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.

The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days of acceptance or rejection. (A.D., “SJDB,” Division of Workers’ Compensatipn, P.O. Box 420603, S.F., CA 94102-3660) If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director.

MANDATORY FORM (Page 1 of 2)STATE OF CALIFORNIA

(08/05)

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK(For injuries occurring on or after 1/1/04)

POSITION REQUIREMENTS

Actual Job Title:Wages: $ per Hour ___ Week ___ Month ___

Is salary of modified/alternative work the same as pre-injury job? Yes ____ No ____

Is salary of modified/alternative work at least 85% of pre-injury job? Yes ____ No ____

Will job last at least 12 months? Yes ____ No ____

Is the job a regular position required by the employer’s business? Yes ____ No ____

Work location: _______________________________________________________________

Duties required of the position:

Description of activities to be performed (if not stated in job description):

Physical requirements for performing work activities (include modifications to usual and customary job):

Name of doctor who approved job restrictions (optional): __________________________ Date ofReport: __________________________

Date of last payment of Temporary Total Disability:

Preparer’s Name:

Preparer’s Signature: Date:

MANDATORY FORM (Page 1 of 2)STATE OF CALIFORNIA

(08/05)

LETTER TO TPARE: MODIFIED/ALTERNATIVE OFFER

(Date)

(Claims Examiner)Gregory B. Bragg & Associates, Inc.P.O. Box 619058Roseville, CA 95661

Re: EMPLOYEE: DATE OF INJURY: CLAIM NUMBER:

Dear (First Name):

(Name of Agency) is offering the (Modified OR Alternative) position of (Job Title) to (Ms. OR Mr.) (Employee's Last Name) since it has been determined that (she OR he) is permanently disabled and unable to return to Usual & Customary duties. I have enclosed the “Notice of Offer of Modified or Alternative Work.” The Employee’s wages at the time of injury were $(U&C Wage) and the current wage offer is $(Offered Wage) . The work location at the time of injury was (U&C Work Location), and the new work location is (New Work Location) . The starting date is (Start Date) .

Please forward the offer of this (Modified OR Alternate) position to the Employee for acceptance. (Please forward the enclosed job description to the Employee’s Treating Physician for approval OR Please contract with a vendor to write a job description of this position, and then forward the completed job description to the Employee’s Treating Physician.)

Thank you for your prompt attention to this matter. Please forward the notice and the Treating Physician’s approval of the position to me as soon as they are received, and then file for closure as appropriate.

Sincerely,

(Name)(Title)

encl: Notice of Offer of Modified or Alternative WorkJob Description


MODIFIED/ALTERNATIVE OFFER ACCEPTANCE LETTER

(Date)

(Employee’s Name)(Employee’s Address)(Employee’s City/State/Zip Code)

Re: DATE OF INJURY: CLAIM NUMBER:

Dear (First Name):

I have just received notification that you have accepted the offer of (Modified OR Alternative) work. Please report to work as detailed below:

Job Title: Department: Supervisor: Work Location: Start Date: Start Time: Wages:

Please feel free to contact me at (Telephone Number) if you have any questions about this job, or about any other aspect of your workers’ compensation claim.

Sincerely,

(Name)(Title)


LETTER TO TPARE: NO MODIFIED OR ALTERNATE PLACEMENT AVAILABLE

(Date)

(Claims Examiner)Gregory B. Bragg & Associates, Inc.P.O. Box 619058Roseville, CA 95661

Re: EMPLOYEE: DATE OF INJURY: CLAIM NUMBER:

Dear (First Name):

This Agency has completed the interactive process and is unable to offer a Modified or Alternative position to (Mr. OR Ms.) (Employee's Last Name). Please proceed with the remainder of this claim as appropriate.

Thank you for your prompt attention to this matter.

Sincerely,

(Name)(Title)
