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Home My WebLink AboutCORRESPONDENCE - GENERAL CORRESPONDENCE - RISKRISK MANAGEMENT LOSS PREVENTION/LOSS CONTROL SELF INSURED EMPLOYEE SAFETY AND WELLNESS TEAM ON AND OFF THE JOB SAFETY SAFETY GLASSES SAFETY SHOES WORKERS' COMPENSATION IF YOU ARE INJURED ON THE JOB... PROCEDURES FOR FILING A WORKERS' COMPENSATION CLAIM Effective January 1, 2003 1. when an injury occurs, you are required to notify your supervisor as soon as possible. 2. All injuries, however slight, should be reported. IF IN DOUBT - FILL IT OUT 3. Should an injury require medical care, report to: Occupational Health Services South Clinic 1330 Oakridge Drive or North Clinic at 1025 Pennock Place -- Phone 495-8450 Hours: 8:00 A.M. to 5:00 P.M. -- Monday - Friday After hours: Report to Convenient Cara/Emergency Department at Poudre Valley Hospital, 1024 South Lemay Avenue, Fort Collins, CO. Phone 495-8000 4. DON'T TAKE CHANCES. IN CASE OF A MEDICAL EMERGENCY CALL 911. 5. Injuries will be treated at the City's designated health care provider, Occupational Health Services at it's south site off Harmony Road at 1330 Oakridge Drive or it's north site 1025 Pennock Place. They will administer your medical treatment even when it's necessary to refer you to a specialist. 6. At the end of each visit Occupational Health Services will give you a "WORK STATUS REPORT." This report will list any work restrictions or modifications and must be given to your supervisor upon your return to work. 7. All medical expenses prescribed by Occupational Health Services will be paid by the City's Workers Compensation Loss Fund throughCannon Cochran Management Services, Inc.(CCMSI), our third party administrator. However, should you receive a bill, forward it to Risk Management at 215 North Mason. 8. Throughout medical treatment, communication regarding the status of your injury will be maintained between you, your supervisor, Occupational Health Services, and Risk Management. 9. THE WORKERS' COMPENSATION INJURY ACCIDENT REPORT MUST BE COMPLETED WITHIN FOUR DAYS OF THE INJURY. IF THE EMPLOYEE IS NOT CAPABLE OF COMPLETING THE FORM, THE SUPERVISOR MUST DO SO. PLEASE SEND THE COMPLETED FORM WITH THE SUPERVISOR'S PORTION OF THE FORM COMPLETED, TO RISK MANAGEMENT. 10. Contact Risk Management at extension 6708 with any questions or concerns regarding workers Compensation. COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION PHYSICIAN'S REPORT OF WORKER'S COMPENSATION INJURY A COPY OF THIS REPORT MUST BE SENT TO THE INJURED WORKER AND THE INSURER. I. REPORT TYPE ❑ Initial ❑ Progress ❑ Closing �. CASE INFORMATION Date of Injury Workers' Comp # Injured Worker's Name Insurer Claim # Social Security # Insurer Name Date of Birth Insurer Phone/Fax Exam Date Employer Name Employer Phone/Fax 3. INITIAL VISIT (only) Injured worker's description of accident/injury Are your objective findings consistent with history and/or work related mechanism of injury/illness ? ❑ Yes ❑ No 4. CURRENT WORK STATUS ❑ Is Working ❑ Not Working 5. WORK RELATED MEDICAL DIAGNOSIS (ES) 6. PLAN OF CARE a. TREATMENT PLAN ❑ Diagnostic tools/tests ❑ Procedures ❑ Therapy ❑ Medications ❑ Supplies ❑ Other It. WORK STATUS ❑ Able to return to full duty on ❑ Unable to work from to ❑ Able to return to modified duty from to ❑ Able to return to part time work on for +_ hrs per day c. LIMITATIONS/RESTRICTIONS ❑ No Restrictions ❑ Temporary Restrictions ❑ Permanent Restrictions ❑ Lifting (maximum weight in pounds) lbs. ❑ Walking hours per day ❑ Repetitive lifting lbs. ❑ Standing hours per day ❑ Carrying lbs. ❑ Sitting hours per day ❑ Pushing / Pulling lbs. ❑ Crawling hours per day ❑ Pinching / Gripping ❑ Kneeling hours per day ❑ Reaching over head ❑ Squatting hours per day ❑ Reaching away from body ❑ Climbing hours per day ❑ Repetitive Motion Restrictions ❑ Other 7. FOLLOW UP CARE AND REFERRALS a. ❑ Return Appointment Date b. ❑ Referral for ❑ Treatment (specify ) Evaluation (specify) ❑ Impairment Rating ❑ Other (specify) Referral Appointment to be made by Injurcil Worker C3 Referring physician's office Referred Provider's Name and Address Phone Number c. ❑ Discharged from care (explain) ❑ Discharged for noncompliance 8. MAXIMUM MEDICAL IMPROVEMENT (MMI) ❑ Injured Worker has reached MMI Date Maintenance care after MMI required? ❑ No ❑ Yes If yes, specify care ❑ Injured Worker is not at MMI, but is anticipated to be at MMI in/on ❑ MMI date unknown at this time 9. PERMANENT MEDICAL IMPAIRMENT ❑ No permanent impairment ❑ Permanent Impairment (attach required worksheets and narrative) ❑ Anticipate permanent impairment ❑ Needs referral to Level It physician for impairment rating (see 7 b above) 10. PHYSICIAN'S SIGNATURE Date of Report Print Name License number Address Telephone Number WC M164 11/00 6.6 Injury Lean Unlike sick leave which does not cover cases of work -related illnesses or injuries, injury leave is paid time off for eligible employees who are placed off work due to an injury or illness that arose out of and occurred in the course and scope of employment with the City. Injury leave is paid in lieu of temporary disability payments. [rev. 626/00] &6.1 Eligible Employees A. All City employees, regardless of category of employment, are eligible to use injury leave. Part-time employees are eligible for injury leave on a pro rata basis based on the number of hours they are regularly scheduled to work each workweek. [rev. 626/00] R Any employee who is unable to work because of an injury sustained in connection with or as a result of his or her violation of a department or City rule or policy pertaining to safety, as determined in the sole discretion of the City, is ineligible to use injury leave. &6.2 Injury Reporting Employees who are injured on the job, however slightly, or learn that they have an occupational illness, injury or disability must immediately report such information to their supervisors and the Risk Management Division. Employees are also required to comply with the City's workers' compensation program requirements, including completing forms and providing information requested by the Risk Management Division and the City's designated physician. 6.6.3 When Injury Leave May Be Used Injury leave allows eligible employees paid time away from work in order to recover from temporary injuries and illnesses that occurred in the course and scope of employment with the City. An eligible employee's use of injury leave will end upon reaching maximum medical improvement as determined by the City's designated physician. Injury leave time may be used by eligible employees under the following circumstances: [rev. 11/12/02] 1. The City's designated physician has placed the employee on a temporary "no work" status because of an injury, illness, disease, or temporary disability, including disability associated with any surgery, arising out of and occurring in the course and scope of the employee's employment with the City; [rev. 11/12/02 ] 2. Necessary medical examinations and treatments for such injury, illness, disease or temporary disability, and reasonable travel time to and from a health care provider for that purpose; City of Fort Collins Personnel Policies and Procedures Revised: November 11, 2002 Section 6 ® WORKERS' COMPENSATION INJURY/EXPOSURE REPORT This form is needed when an employee is injured while in the course of employment. Ciry o(FOK Collins Employee should complete Part I and Part II in full; Supervisor should complete and sign Part III. If employee is not able to complete form, supervisor should do so. Submit to Risk Management within four days of injury. PART I — EMPLOYEE Employee's Name (First, Middle, Last) Social Security Number Sex Employee Home Telephone No. ❑ Male ❑ Female Employee's Street Address City State Zip Code Occupation Age Birthdate Dependents How long has employee Job assigned when injured/exposed? Length of experience worked for this employer? at this assignment? Mo. Day Yr. ❑ Yes ❑ No Year of Education Completed (circle one) Race 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ❑ Asian ❑ Black ❑ Hispanic ❑ White ❑ Do Not Wish To Answer DO NOT WRITE IN THIS COLUMN PART II — INJURY INFORMATION Injury Date What happened to cause this Injury or Illness? Describe employee's activities when injury or illness occurred with details of how event or exposure occurred (include name(s) of other individuals involved, tools, machinery, objects, vapors, chemicals, radiations, unnatural motions of employee, sic.) Mo. Day Yr. Also, specify the Items which directly Injured the employee and caused the accident or Illness. Injury Time ❑ a.m. ❑ P.M. Please list any safety concerns: Injury Description (State exactly the part of the body affected and the name of injury or illness) Names of Witnesses Name of Employer Representative Notified Place of Accident/Exposure Treatment received: ❑ First Aid ❑ Emergency Room ❑ Doctor ❑ None Name and Address of Treating Doctor It is unlawful to knowingly provide false, Incomplete, or misleading facts or Information to an Insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any Insurance company or agent of an Insurance company who knowingly provides false, Incomplete or misleading facts or Information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to settlement or award payable from Insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S. Employee Signature - Date PART III — SUPERVISOR MUST COMPLETE THIS SECTION OF THE REPORT Employee's Scheduled Work Week When Injured Hrs. Per Day Days Per Week Last Day Worked Mo. Day Yr. Date Employer Notified Mo. Day Yr. Modified Work Available if Applicable ❑ Yes ❑ No If No, why? Employee's Usual Work Schedule Hrs. Per Day Days Per Week ❑ Date Returned to Work ❑ Estimated Date of Return Mo. Day Yr. Did injury cause death? ❑Yes ❑ No Date of death Mo. Day Yr. Please list any safety concerns: Did injury occur because of: ❑ Intoxication ❑ Failure to use Safety Devices ❑ Failure to Obey Rules Cl Not Applicable Date of Report Work Phone Supervisor's Signature DO NOT SEPARATE I RETURN ALL COPIES TO RISK MANAGEMENT Green - Risk Management Yellow - Department Blue - Employee Pink - Workers' Compensation Administrator 06-13-97 Occupational Health Services — North Clinic at 1025 Pennock Place 9 Rd. 9' tr P W WRRCRO CY f� +.r. E3 Ej Occupational Health Services — South Clinic at 1330 Oakridge Drive ' L i MUM ggtt{{yyIII'm-M; lr 91 NIB � 6 B ■ _ N �o-i � t e-.. Via. 41 x & �" � r •R�.`i. ce � xz !'".. S �. .tw ..-,^�_ x�.• 9�.. .ry ",''�i.as $ffi': t_ %n� 33'r Y:'9�'�"a``_ $� E&5:.. c., n I nn. �o a, City of Fort Collinshority PROCEDURES IN CASE OF A VEHICLE ACCIDENT 1) IMMEDIATELY CONTACT THE LOCAL LAW ENFORCEMENT AGENCY to obtain a police report and medical assistance, if needed. In Fort Collins, call 911. 2) IF A VEHICLE NEEDS TO BE TOWED: During Business Hours Contact: Fleet Services ....................................... (970) 221-6613 Transfort .............................................. (970) 221-6625 Poudre Fire Authority .......................... (970) 221-6766 After Business Hours: City and PFA Staff Vehicles Contact Police Dispatch, City of Fort Collins ..... (970) 221-6540 All Other PFA Vehicles Contact Jim Mirowski ................ (970) 498-7995 (Pager #8012) OR Choice City Towing ............................. (970) 221-1887 3) MAKE NO STATEMENTS ADMITTING LIABILITY. 4) CONTACT YOUR SUPERVISOR IMMEDIATELY. It is the responsibility of the supervisor to contact Risk Management immediately. 5) DO NOT LEAVE THE SCENE OF THE ACCIDENT unless authorized by your supervisor or the law enforcement officer or transported by ambulance. 6) COMPLETE AN INCIDENT REPORT FORM. This form can be obtained from Risk Management. Send the report to Risk Management within 24 hours. If the employee is not able to complete the form, the supervisor should do so. 7) REPORT IMMEDIATELY TO RISK MANAGEMENT ANY ACCIDENTS INVOLVING INJURIES OR FATALITIES. 14 (see reverse side for insurance identification card) e