PEARLAND INDEPENDENT SCHOOL DISTRICT WORKERS’ …

PEARLAND INDEPENDENT SCHOOL DISTRICT WORKERS' COMPENSATION PROCEDURES

REPORTING PROCEDURES:

1. Employees injured on the job must report such injury to the campus nurse or his/her immediate supervisor when the injury occurs. This information should then be forwarded to the HRS department, attention Benefits. If for some reason it is after HRS office hours the employee or employer representative can call Texas Mutual Insurance at 1-800-859-5995 to report the injury and a claim number can be provided at that time. Please note: District Contact person for Workers' Compensation is Victoria Trevino, Benefits Specialist, at 832-736-6120 or ext. 66120.

2. Submit the following forms, fully completed and signed, via fax to 281-412-1540, or via e-mail at benefits@ within 24 hours of the injury. These forms are located on the Pearland ISD website under DepartmentsBenefitsWorkers Comp.

Employer's First Report of Injury or Illness [DWC1] [Fill out section 1 thru 29 only][the employee does not sign the DWC1]

Employee Acknowledgement of Workers' Compensation Network form Workers' Compensation Wage Benefits Use of Leave Authorization Incident Analysis form

Note: If employee is not missing time from work, or seeking treatment, only the Employers First Report of Injury and Acknowledgement of Workers' Compensation Network form are required.

3. Workers' Compensation Wage Benefits form declares to the District the employee's choice to use available paid leave in conjunction with workers' compensation benefits. Temporary Income Benefits [TIBS] eligibility does not begin until the eighth day of absence. Failure to submit this form will result in the use of any and all available leave including earned vacation.

4. The injured employee must receive the "Injured Worker Rights and Responsibilities" information, which is located on the Pearland ISD website.

5. The Accident Investigation Report form must be filled out after an accident. Please make sure this form is filled out in its entirety as this will help determine what action/preventive measure should be taken.

MEDICAL ATTENTION:

1. Do not hesitate to call "911" for emergency assistance.

2. Provide the injured employee a list of health care providers. However, an injured employee needing medical attention in a non-emergency situation may go to any approved Texas Mutual network health care provider. Health care providers can be located at .

FOLLOW-UP PROCEDURES:

1. It is the responsibility of the injured employee to call his/her supervisor each week to report work status. Following each health care provider appointment, the injured employee must provide proof of the office visit to the Human Resource Services office, in person.

2. The Human Resource Services office will notify the Department/Campus of any changes in the employee's work status (additional loss of time, termination or resignation) via email or phone the day that the change occurs.

3. If the employee seeks treatment, or misses 1 day, they must have a "Return to Work Notice" issued by Human Resource Services before they are allowed to go back to work.

REVISED- 010/2018- VT

WORKWELL,TX

Employee Acknowledgment of Workers' Compensation Network

I have received information that informs me how to get health care under my employer's workers' compensation insurance.

If I am hurt on the job and live in a service area described in this packet, I understand that:

? I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care physician to agree to serve as my treating doctor. If I select my HMO primary care physician as my treating doctor, I will call Texas Mutual Insurance Company at (844) 867-2338 to notify them of my choice.

? I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me to a specialist. If I need emergency care, I may go anywhere.

? Texas Mutual will pay the treating doctor and other network providers for the treatment for my compensable injury.

? I may have to pay the bill if I get health care from someone other than a network doctor without prior network approval.

Knowingly making a false workers' compensation claim may lead to a criminal investigation that could result in criminal penalties such as fines and imprisonment.

Signature

I live at: Street address

Date

Printed name

City

State

Zip code

Name of network: WorkWell, TX

To the employer:

Each employee must sign this form when you begin the program or within 3 days of being hired, and at the time an injury occurs. Please indicate at which point this acknowledgement was completed.

o Initiating the network program (companywide)

o Initial employee notification (new hire)

o Injury notification (Date of injury: I

I )

Keep this completed form in the employee's personnel file. It could be requested by Texas Mutual.

TO BE COMPLETED BY EMPLOYEE

PEARLAND INDEPENDENT SCHOOL DISTRICT

Workers' Compensation Wage Benefits

DWC Rule 129.2 Entitlement to Temporary Income Benefits: Effective December 26, 1999 DWC Rule 129.2 eliminates "double dipping." An employee of a district, ESC, or public community college cannot receive payment for a full days pay in addition to WC wage benefits (TIBS).

Employee Choice: I am absent from duty because of a job-related illness or injury. I understand that I am not eligible for workers' compensation weekly income benefits until my absence exceeds seven (7) calendar days. I choose the following option:

[ ] I choose to use all available paid leave. I also understand that I will not receive workers' compensation temporary weekly income benefits (TIBS) until I have exhausted all my paid leave.

[ ] I choose not to use any available paid leave at this time. I understand that I will not receive any regular salary from Pearland Independent School District while receiving weekly income benefits under workers' compensation. No available paid leave will be deducted from my leave balance. I further understand that by selecting this option I will receive only workers' compensation income benefits for any absences resulting from my work related illness or injury.

If you are absent from duty because of a work related injury or illness for more than fourteen (14) days, workers' compensation income benefits (TIBS) will be paid for your first seven (7) days of absence unless you have used any of your available paid leave for any portion of the first seven days.

THIS FORM MUST BE RETURNED TO THE BENEFITS DEPARTMENT NO LATER THAN SEVEN (7) CALENDAR DAYS FROM THE DATE OF INJURY. IF FORM IS NOT RETURNED THE DISTRICT WILL USE ANY AVAILABLE LEAVE. THIS ACTION IS IRREVOCABLE

Workers' Compensation Benefits are paid as a percentage, 70% - 75% of your average weekly wage.

Employee Name (Please Print)

Employee Signature

Social Security Number Department/Campus

Date Signed

Date Received

MUST BE RETURNED TO EMPLOYEES BENEFITS OFFICE

Revised 09/11/2012

PEARLAND INDEPENDENT SCHOOL DISTRICT

USE of LEAVE AUTHORIZATION

Employee Name (Please Print)

Employee Identification Number

Job Assignment (Campus/Dept) ________________________________________

Employee Signature

Date Signed

Check Appropriate Box Indicating Type of Leave Requested:

Family/Medical/Military Leave Worker's Compensation (Date of Injury: _____________) Temporary Disability Leave Military Leave Available Leave

Select the order in which earned leave will be taken during your absence. You may also decide on the number of days per category to be charged to your leave balances.

Failure to designate the order will result in your leave being charged as follows: 1) State Sick Leave; 2) State Personal Leave; 3) Local Leave. 4) Vacation/Non-Duty Days.

Please circle the order you would like to use your leave and if you so choose, fill in the number of days per category.

[1] [2] [3] [4] [1] [2] [3] [4] [1] [2] [3] [4] [1] [2] [3] [4]

I choose to use I choose to use I choose to use I choose to use

days of State Sick leave. days of State Personal leave. days of Local leave. days of Vacation/Non-duty days.

FAILURE TO RETURN THIS FORM WILL RESULT IN LEAVE CHARGED AS STATED ABOVE. YOUR SELECTIONS ARE FINAL.

FORM MUST BE RETURNED TO HUMAN RESOURCE SERVICES

Revised 2/19/2018

INCIDENT ANALYSIS FORM

? Incident analysis helps you in reducing or preventing future occupational injuries and illnesses.

? This form requests all the information that the DWC says you must record for each on-the-job injury, fatality, and occupational disease. Employers must keep injury records for five years after the last day of the year in which the injury occurred.

This is an

TODAY'S DATE DATE REPORTED COMPANY DEPARTMENT SUPERVISOR PHONE NO.

1. Name of Person Involved

Injury

Disease

Fatality

Near-miss

2. Sex 3. Social Security Number

4. DOB

5. Date of Incident

6. Home Address ______________________________________

______________________________________

Phone (

)

13. Name and Address of Treating Physician ______________________________________

______________________________________

Phone (

)

16. Name and Address of Hospital

______________________________________

______________________________________

19. Employee's Wage (pay per Hour)

7. Time and Day of Incident

8. Specific Location of Incident

_______ a.m; _______ p.m; day of week ____ Was it on employer's premises? yes no

9. Employee's Occupation

10. Job Task at Time of Incident

11. Length of Service

______________Years; ___________ Months 14. Employment Category

Regular, full-time Temporary Regular, part-time Non-employee Seasonal

12. Employee was Working

Alone

With Fellow Workers

Other

15. Experience in Occupation at Time of Incident

Less than 1 month

1 to 5 month

6 months to 1 year

1 to less than 5 years

5 or more years

17. Phase of Employee's Workday at Time of Injury

During break period

During meal period

Entering or leaving the building

Performing work duties

18. Name of employee's immediate Supervisor at time of incident

Incident?

20. Other Witnesses

Working overtime Other (explain below)

Witnessed

Yes No

21. Voluntary benefits paid by the employer, ________________________________________________________________________________ if any

22. PART of BODY INFURIED or AFFECTED

Skull, Scalp

Jaw

Abdomen

Shoulder

Eye

Neck

Back

Upper Arm

Nose

Spine

Pelvis

Elbow

Mouth

Chest

Other Body Part Forearm

Wrist Hand Finger Hip

Knee

Foot

Thigh

Toe

Lower Leg

Ankle

Other ___________________

23. NATURE of INJURY or ILLINESS

Puncture

Bruise, Contusion Skin Disorder

Laceration

Dislocation

Burn

Fracture

Abrasion

Respiratory

Heat/Cold Stress Hearing Loss Chemical Exp.

Amputation

Muscle Sprain Cumulative Trauma Disorder

Insect/Animal Bite Muscle Strain Irritation

Foreign Body Hernia

Infection

Other ____________________________________________________________

24. DISPOSITION

25. DIAGNOSIS

26. SEVERITY

Days away from work # __________.

Restricted work days # ___________.

Date returned to work # __________.

Sent to:

Doctor Hospital

______________________________ ______________________________ ______________________________

First Aid

Medical Treatment

Lost Work Days Fatality

Other: Specify

___________________________

27. WHAT CONDITION of TOOLS, EQUIPMENT, or WORK AREA CONTRIBUTED TO INCIDENT?Not Applicable

Close Clearance/Congestion

Floors/Work Surfaces

Inadequate Housekeeping Defective Tools/Equipment/Vehicle

Hazardous Placement

Inadequate Ventilation

Equipment Failure

Illumination

Inadequate Warning System

Equipment/Workstation Design

Inadequate Guards/Barrier Inadequate/Improper P.P.E.

28. WHAT CAUSED or INFLUENCED SUBSTANDARD CONDITIONS?

No Substandard Conditions

Abuse or Misuse

Inadequate Supervision

Inadequate Purchasing

Inadequate Engineering

Inadequate Maintenance

Inadequate Tools/Equip..Mat.

Improper Work Surfaces Wear and Tear

Lack of Knowledge/Training

Improper Motivation

Inadequate Capacity

Lack of Skill

29. WHAT ACTION or INACTION CONTRIBUTED to the INCIDENT? Not Applicable

Failure to Make Secure Nullified Safety/Control Devices Used Equipment Improperly Running/Rushing/Acting in Haste Improper Technique Other _________________________

Under Influence Drugs/Alcohol Used Defective Equipment Improper Lifting Improper Loading Improper Position

Failure to Warn/Signal

Inadequate/Improper P. P. E. Use

Horseplay/Distractive Active Operating at Improper Speed

Operating Procedure Deviation

Unauthorized Actions

Used Wrong Tool/Equipment

Servicing/Operating Equipment

30. PROBABLE RECURRENCE

31. LOSS SEVERITY POTENTIAL

Frequent

Occasional

Rare

Major

Serious

Minor

32. PREVENTIVE MEASURES: (What corrective actions have been taken or are planned to prevent a recurrence?)

Improve Enforcement

Improve Clean-up Procedures

Repair/Replace Equipment Corrective Counseling

Improve Storage/Arrangement

Rotation of Employee

Eliminate Congestion

Improve/Change Work Method

Identify/Improve P. P. E

Install/Revise Guards/Devices

Task Analysis to Be Completed

Task Analysis/Procedure Revision

Improve Design/Construction

Job Reassignment of Employees

Use Other Materials/Supplies

Improve Illumination

Mandatory Pre-Job Instructions

Improve Ventilation

Reinstruction of Employees

Other _________________________

33. EMPLOYEE'S DESCRIPTION of INCIDENT (Attach sheet for additional comments) Comments sheet

34. SUPERVISOR'S DESCRIPTION of INCIDENT (Attach sheet for additional comments) Comments sheet

35. SPECIFIC CORRECTIVE ACTIONS or PREVENTIVE MEASURES TAKEN

Corrective Action Taken

Person Responsible

Target Date

Date Completed

________________________________ Supervisor's Signature

__________ Date

Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System

As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). This assistance is offered at local offices across the State. These local offices also provide other workers' compensation system services from the Texas Department of Insurance (TDI). TDI is the State agency that administers and regulates the workers' compensation system through the Division of Workers' Compensation (DWC).

Many services provided by OIEC and DWC can be completed over the telephone. You can contact OIEC by calling the toll-free telephone number 1-866-EZE-OIEC (1-866-393-6432). Additional information, including office locations, is available on the Internet at: oiec.. You can contact DWC by calling the toll-free telephone number 1-800252-7031. Information about DWC is available on the Internet at: tdi..

Your Rights in the Texas Workers' Compensation System:

1. You have the right to hire an attorney to help you with your workers' compensation claim. For assistance locating an attorney, contact the State Bar of Texas' lawyer referral service at 1-877-983-9227 or . Attorney referral information can also be found on OIEC's website at oiec..

2. You have the right to receive assistance from OIEC if you do not have an attorney. OIEC Customer Service Representatives and Ombudsmen are available to answer your questions and provide assistance with your workers' compensation claim by calling OIEC or visiting an OIEC office. You must sign a written authorization before an OIEC employee can access information on your claim. Call or visit an OIEC office to fill out the written authorization. Customer Service Representatives and Ombudsmen are trained in the field of workers' compensation and can help you with scheduling a dispute resolution proceeding about your workers' compensation claim. An Ombudsman can also assist you at a benefit review conference (BRC), contested case hearing (CCH), and an appeal. However, Ombudsmen cannot make decisions for you or give legal advice.

3. You may have the right to receive medical and income benefits regardless of who was at fault for your injury, with certain exceptions. Your beneficiaries may be entitled to death and burial benefits. Information about the exceptions can be found at tdi. or by visiting with OIEC staff.

4. You may have the right to receive medical care to treat your workplace injury or illness for as long as it is medically necessary and related to the workplace injury. You may have the right to reimbursement of your incurred expenses after traveling to attend a medical appointment or required medical examination if the trip meets qualifying conditions.

5. You may have the right to receive income benefits for your work-related injury. There are several types of income benefits and eligibility requirements. Information on the types of income benefits that may be available and the eligibility requirements can be found at tdi. or by visiting with OIEC staff.

6. You may have the right to dispute resolution regarding income and medical benefits. You may request Medical Dispute Resolution if you disagree with the insurance carrier regarding medical benefits. You may request Indemnity (Income) Dispute Resolution if you disagree with the insurance carrier regarding income benefits. The law provides that your dispute proceedings will be held within 75 miles from your residence.

7. You have the right to choose a treating doctor.

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