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Return to Work 101 Injury Reporting May 14th, 2009. Presented by: Cathy Stein-Romo Chief Executive Office Risk Management/WC Unit (213) 738-2228 Topics Covered. WC/RTW Overview Forms/Process -Completing forms -Seeking medical treatment via Pre-designation OR

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return to work 101 injury reporting may 14th 2009

Return to Work 101 Injury ReportingMay 14th, 2009

Presented by:

Cathy Stein-Romo

Chief Executive Office

Risk Management/WC Unit

(213) 738-2228

topics covered
Topics Covered
  • WC/RTW Overview
  • Forms/Process

-Completing forms

-Seeking medical treatment via Pre-designation



  • Work Hardening (WHTAA)
  • Maintaining File/Contact with Employee
workers compensation overview
Workers’ Compensation Overview
  • Injury definition: any injury or disease arising in the course and scope of employment
    • Specific
    • Cumulative
    • Presumptive (safety only)
  • Applicable labor code section;

“…shall be liberally construed by the courts with the purpose of extending their benefit for the protection of persons injured in the course of their employment.” (LC3202)

workers compensation overview cont
Workers’ Compensation Overview, Cont…
  • Third Party Administrator
    • Contractor hired by County of Los Angeles to administer workers’ compensation benefits for County employees
    • Decides whether workers’ compensation claims are compensable (work-related)
    • Decision must be made within 90 days of receiving claim form
return to work overview
Return to Work Overview


Program designed to return employees to work in a productive capacity as quickly as possible after an injury or illness.


Minimize the costs of injuries and illnesses while maintaining an inclusive work environment.

injury reporting form packet contains
Injury Reporting Form Packet Contains…
  • Emergency
  • Non-Emergency
  • Refusal of Treatment
  • Referral to Treatment
  • CEO Website:

breakdown of injury reporting
Emergency Injury Reporting

Non-Emergency Injury Reporting

Employee Seeks Treatment

Employee Injury/Illness File

Employee on Temporary Total Disability

Employee Released to Full Duties

Employee Released to Modified or

Alternate Work

Required Forms

Breakdown of Injury Reporting
emergency injury reported cont
Emergency Injury Reported, Cont..

Once the situation is stable, you


  • Complete the Job Description form.
  • Complete the DWC1 Claim Form, and the Employer’s Report of Injury (5020) and call into the 800 number within 24 hours.

We have included an optional fax cover sheet for your convenience…

non emergency injury reported
Non-EmergencyInjury Reported
  • If Employee Declines Treatment:
  • Employee must complete the Employee’s Statement Declining Treatment form.
  • A copy of the form must be sent to the RTW Coordinator or Personnel.
  • 2. Employee must sign Receipt of Employee Packet, and be given the packet.
employee seeks treatment
Employee Seeks Treatment

Review the Employee’s Guide for Injury Reporting with

the employee.

Complete the Injury Reporting forms with the

employee. The packet must contain the four

forms below:

  • The completed Treatment Referral Slip
  • The completed Treating Physician’s letter (for physical injuries only)
  • A copy of the blank Patient Status Report
employee seeks treatment cont
Employee Seeks Treatment Cont…
  • And, a copy of the completed Job Description

should be included in the Medical Provider


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

employee seeks treatment cont1
Employee Seeks Treatment, Cont…
  • Ask the employee if they have Pre-designated a treating physician.
  • If they have not, send them to the Medical Provider Network (MPN) Initial Treatment Center (ITC). A list of those centers can be obtained on the County’s MPN website at:

employee seeks treatment cont2
Employee Seeks Treatment, Cont…
  • Fill out the DWC1 Claim Form, and Employer’s Report (5020) form. The injury must be called into the 800 number within 24 hours upon notice of the injury.
  • Call the 800 number and report the injury.

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

mpn initial treatment centers itc
MPN Initial Treatment Centers (ITC)

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)

employee on temporary total disability employee is taken off work by physician after injury
Employee on TemporaryTotal Disability Employee is taken off work by physician after injury
  • Location Supervisor should fax a copy of the Patient Status Report to the RTW Unit/Personnel.
  • Make sure that the time card is coded appropriately.
  • Call the employee for status.

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

employee released to full duties
Employee Released to Full Duties
  • Return the employee to work.
  • Communicate with the employee to make sure they are able to continue working their Usual and Customary (U & C) duties.
  • The department RTW Unit should be informed of status in writing, and of any problems or concerns.
  • Close the employee injury/illness file in 45 days from the date of injury if the employee continues to work their U & C job.

Employee Released to Modified or Alternate WorkPhysician has provided restrictions that prevent employee from immediately returning to their Usual and Customary (U&C) job

Review the work restrictions to make sure they are compatible with the duties listed in the job description.
  • If the work restrictions are compatible, return the employee to work.
  • If modification of the job duties is required, make the necessary modifications.
  • Communicate those temporary modifications and time limits to the employee.
  • 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 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 alternate work, a WHTAA must be completed with the employee.
If no alternate 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 with the employee on their first day back to work.
  • Make sure a signed WHTAA is obtained and maintained between the department RTW Unit and the work location/supervisor/RTW Coordinator.
If there is no work assignment for the employee, the supervisor should continue to call the employee weekly (Reminder: log all phone calls on the Telephone Log).
  • 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.
review of required forms for reporting an industrial injury
Review of Required Forms for Reporting an Industrial Injury
  • Receipt of Employee Packet
  • Employee’s Statement Declining Medical Treatment
  • First Alert or other proof of Fax as appropriate
  • DWC 1 Claim Form
  • Employer’s Report (5020) Form
  • Job Description Form
  • Treating Physician’s Letter
  • Treatment Referral Slip
  • Work Hardening Transitional Assignment Agreement
  • Weekly Call Verification Sheet
  • To locate more forms see:
review of employee responsibilities
Review of Employee Responsibilities
  • 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
employee injury illness file
Employee Injury/Illness File

It is important that an injury/illness file be maintained on

employees. The injury/illness file should contain, at a minimum, the following documents:

  • A copy of the Claim Form (DWC Form 1)
  • A copy of the Employer’s Report (5020)
  • Employee’s Report of Accident
  • Supervisor Weekly Telephone Log Sheet
  • Copy of the Job Description/Essential Job Functions listing
  • Patient Status Reports
  • Work Hardening Agreements
  • Any other documentation that you may receive on this injury