RETURN TO WORK 101 INJURY REPORTING . Chief Executive Office Risk Management RETURN TO WORK Unit. Workers’ Compensation/Return-To-Work (RTW) Forms/Process Completing Forms Seeking medical treatment via Pre-designation or Initial Treatment Center (ITC) Work Hardening (WHTAA)
RETURN TO WORK 101INJURY REPORTING
Chief Executive OfficeRisk Management RETURN TO WORK Unit
“…shall be liberally construed by the courts with the purpose of extending their benefit for the protection of persons injured in the course of their employment.” (LC3202)
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
EMPLOYER’S REPORT OF OCCUPATIONAL INJURY/ILLNESS (5020 FORM)
JOB DESCRIPTION FORM
JOB DESCRIPTION FORM
FIRST ALERT FORM
Send the four documents with the employee to the
Pre-designated physician OR ITC, as applicable.
A list of those centers can be obtained on the County’s MPN website at:
PREDESIGNATION OF PERSONAL PHYSICIAN FORM
Fill out the DWC1 Claim Form, and Employer’s Report (5020) form. The injury must be called into the Toll-Free number within 24 hours upon notice of the injury.
Call the Toll-Free number and report the injury.
In some departments, the RTW Unit staff calls in the injury, in others the supervisor or location designee calls it in.
If Employee has not Pre-designated their personal treating physician, the work location Supervisor or designee must direct them into the County’s Medical Provider Network (MPNs), via an Initial Treatment Center (ITC).
If modification of the job is done, a Work Hardening Transitional Assignment Agreement (WHTAA) must be completed with the employee. (This should be done during the Interactive meeting and by either or both the RTW Unit staff or the location Supervisor or designee along with the employee.)
Location Supervisor/designated staff and department RTW Unit staff should both have a signed copy of the WHTAA, along with the employee.
Retain a copy of the WHTAA in the employee’s injury/illness file.
If modification of the job is not possible, explore available job tasks within the work unit.
If the location is able to provide alternative work, a WHTAA must be completed with the employee.
If no alternative or modified job is available after a thorough and reasonable search is conducted, contact the Supervisor/Management at work location and human resources staff to assist with a plan to monitor situation and expand search for other job placement opportunities within the department.
Catalog a follow-up date with department staff.
When an assignment is located, complete the WHTAA form with the employee on their first day back to work.
Make sure a signed WHTAA form is obtained and maintained between the department RTW Unit and the work location/supervisor/RTW Coordinator.
If there is a problem reaching the employee at home, document attempts on the Telephone Log and work with other County TPA staff as appropriate to verify contact information. If necessary you can contact the treating physician to request medical certification reflecting any restrictions or to verify employee is taken off work.
If you suspect any behavior or receive any information regarding fraudulent activities or abuse, this information should be shared with our TPA staff once their file is set up.
Complete DWC-1 Employee Claim Form
Complete Employee’s Report of Accident
Return the Completed forms to your supervisor/including all Medical Certifications from your treating physician
It is important that an injury/illness file be
maintained on employees. The injury/illness
file should contain, at a minimum, the following