Accident/Incident & Workers Compensation

Packet

Revised 7/12/2006 Getz Fire Equipment Page 1

Accident/Incident & Workers Compensation Program

The following information is to assist you in completing the Accident/Incident & Workers Compensation Program and keep track of all employee doctor visits, forms, etc. The following items are included in the packet:

• Written Program, Page 2

• Accident/Incident Report (filled out by Kathy Thompson), Page 4

• Accident/Incident Forms:

• Employee Accident/Incident Form, Page, 5 All employees should fill out in their own words exactly what happened. This information will be

used by management to complete the Supervisor Investigation Form. This should be done immediately.

• Supervisor Investigation Form, Page 6 All accidents/incidents should be investigated to find the root cause and prevention measures of

the incident. This should be done immediately.

• Attending Physician Form, Page 7 Employees take this form to the doctor for any work-related visit and are required to return the form immediately to Kathy Thompson. On this form the doctor will indicate if there are work restrictions. • Return To Work Letter, Page 8

This can be attached to the Physicians Form to let them know you have a Return To Work Program.

• Transitional Return To Work Log, Page 9 & 10 This should be completed on all modified duty jobs. This form is completed by the supervisor and the employee. They review the jobs performed that day by the injured employee to make sure they are working within their restrictions and that nothing is aggravating the injury. • Modified Duty Letter, Page 11 This letter is sent to the injured employee in verification of the verbal modified duty job offer.

• COPY ALL COMPLETED FORMS FOR YOUR RECORDS

Revised 7/12/2006 Getz Fire Equipment Page 2

Accident/Incident & Workers Compensation

It is the goal of Getz Fire Equipment Co. to enhance the employee’s rehabilitation and facilitate their return to work following a work related injury until the employee is able to return to his/her customary and usual duties.

*Items 1-4 are required for all accidents, incidents, and/or workers compensation claims. Procedure 1. An employee who has an accident/incident while in the course of their employment is required to report their accident/incident to their supervisor immediately and complete an employee accident/incident report, (page 5). A drug and alcohol test will be required if medical attention is needed. 2. The initial report is then given to Kathy Thompson to complete the Accident/Incident Report (page 4) and submit it to the insurance company within 24 hours. 3. The injured employee’s supervisor then conducts their investigation of the accident/incident and documents the root causes, contributing factors and prevention measures. If medical attention is needed then the investigation can be completed at a later time, but within 48 hours. 4. The employee is then given a cover letter to give to their physician, Attending Physician’s Return to Work Recommendations Record, and a copy of their normal job description. (Page 7 & 8) *Items 5-18 are required if an employee is taken off of work. 5. If an employee is taken off of work, Kathy Thompson will notify the insurance company. Kathy Thompson also contacts the medical provider regarding the Return to Work Program (RTW). 6. Employees are required to bring their Physicians Return to Work Recommendations Record into Kathy Thompson on the same day as their appointment unless their appointment is at the end of the business day. The following day would then be acceptable. Out of town employees are required to fax their forms that day. 7. No employee can return to work without a completed release form. Getz Fire Equipment Co. and the insurance company will do everything possible to obtain a completed RTW form for an employee who is taken off of work. 8. Once a RTW form is received, duties will be identified based on their restrictions. A copy of the employee’s duty list will be provided to them and their supervisor. 9. A verbal return to work offer will then be made to the employee by their supervisor. The supervisor will inform Kathy Thompson once the verbal offer is made. 10. The verbal offer will then be followed by a written letter (page 11). The letter will be sent certified, return-receipt. It may also be given to the employee. All employees released for modified duty will receive a letter once they are released. THERE WILL BE NO EXCEPTIONS. 11. The injured employee will complete the temporary Transitional Return to Work Log (page 10) upon their return to work. The Log will be completed for every injured employee on restricted duty regardless of position, hours worked, or length of time he/she is on restricted work. THERE WILL BE NO EXCEPTIONS.

Revised 7/12/2006 Getz Fire Equipment Page 3

12. Temporary Transitional Return to Work Logs must be forwarded onto Kathy Thompson and retained in the employee’s claim file for future reference. 13. Employee’s found working outside of their restrictions will be disciplined in accordance with our progressive disciplinary process. THERE WILL BE NO EXCEPTIONS. 14. Modified duties will be provided for the maximum number of hours the employee is released by their physician. 15. The employee will be paid at their full rate of pay or their calculated hourly rate. 16. While on restricted work, for a work-related injury, the employee is responsible to report for all scheduled Physician and Therapy appointments. Kathy Thompson and Division Manager must be informed of all appointments. An attempt should be made to schedule all appointments during non-working hours provided that the medical facility can accommodate those hours. Keep in mind that if appointments are scheduled during work, to speak to your employer regarding making up the time. 17. Transitional job duties are in nature and are subject for review on a weekly basis, as to their healing progress, reduction in restrictions, what jobs or duties is available and future medical treatment. 18. If this program is not followed by the employee in its entirety, the employee will be disciplined in accordance with our progressive disciplinary process. THERE WILL BE NO EXCEPTIONS.

Revised 7/12/2006 Getz Fire Equipment Page 4

ACCIDENT/INCIDENT REPORT

Injury (work related) Illness (work related) Property Damage Incident Employee Name (First, Middle, Last)

Social Security Number

Sex Male Female

Employee Home Telephone Number

Employee's Street Address

City

State

Zip

Age Birth date Job Title Department Mo. Day Yr.

Start Time End Time Hrs. Per Day Hrs. Per Wk. Days Per Wk. Start Time End Time Employee's Scheduled Work Week When Injured

AM PM

AM PM

Normal Full-Time Schedule for Injured's Work

AM PM

AM PM

Injury Date Hour of Day Last Day Worked Start Date No Lost Time Mo. Day Yr. Mo. Day Yr. Mo. Day Yr. Date Returned to Work Mo. Day Yr. AM PM Estimated Date of Return

Did employee seek medical attention? Yes No If yes, name of treating physician: Name of clinic or hospital: Will the employee complete a drug screening? Yes No Names of Witnesses (Attach witness statements.) 1. 2. Injured Employee's statement of what happened. (Identify circumstances and equipment involved.)

1.

2.

3.

4.

5.

What is the injury/illness? (Be specific.)

Part of Body Affected Type of Injury Eye Head Neck Back Arm Shoulder Fingers Leg Knee

Hip Foot Wrist Hand Toes Ankle Elbow Trunk (Other than back) Other

Cut/Abrasion Bruise/Contusion Foreign Object Burn Break Sprain/Strain Exposure Repetitive Motion Other

I believe that the answers to the above questions are true to the best of my knowledge.

Employee's Signature

Date

Supervisor's Signature

Date

Notified

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EMPLOYEE ACCIDENT / INCIDENT REPORT

Employee Name: Facility:

Incident Date: Incident Time:

Date Supervisor Notified:

Exact Body Part Injured:

Describe What Happened:

What do you think caused your accident/incident?

What do you think could be done to prevent this type of accident/incident from occurring again?

Employee Name:

Date Report Completed:

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SUPERVISOR ACCIDENT / INCIDENT INVESTIGATION REPORT

Employee Name:

Incident Date: Incident Time:

Describe What Happened (Be specific, list all information):

Witnesses:

ROOT CAUSE of the Accident/Incident (the one cause, that if it was not present, the incident would never have happened):

CONTRIBUTING CAUSE(S) of the Accident/Incident:

1.

2.

3.

Prevention measure(s) for ROOT CAUSE and CONTRIBUTING CAUSES:

Activity Responsible Person Target Date Date Completed

1.

2.

3.

Person Completing Investigation:

Date Completed:

Revised 7/12/2006 Getz Fire Equipment Page 7

ATTENDING PHYSICIAN'S RETURN TO WORK RECOMMENDATIONS RECORD

Claim No.

Patient's Name (First) (MI) (Last) Date of Injury TO BE COMPLETED BY ATTENDING PHYSICIAN – PLEASE CHECK Diagnosis/Condition (Brief Explanation) I saw and treated this patient on

and based on the above description of the patient's current medical problem:

(date)

1. Recommend his/her return to work with no limitations on

(date)

2. He/She may return to work on

capable of performing the degree of work checked , below with the following limitations:

(date)

Sedentary Work. Lifting 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work. Lifting 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling of arm and/or leg controls.

Light Medium Work. Lifting 30 pounds maximum with frequent lifting and/or carrying of objects weighing up to 20 pounds.

Medium Work. Lifting 50 pounds maximum with frequent lifting and/or carrying of objects weighing up to 25 pounds.

Medium Heavy Work. Lifting 75-80 pounds maximum with frequent lifting and/or carrying of objects weighing up to 40 pounds.

Heavy Work. Lifting 100 pounds maximum with frequent lifting and/or carrying of objects weighing up to 50 pounds.

1. In an 8 hour work day patient may:

a. Stand/Walk None 1-4 hours 4-6 hours 6-8 hours

b. Sit 1-3 hours 3-5 hours 5-8 hours

c. Drive 1-3 hours 3-5 hours 5-8 hours

2. Patient may use hand(s) for repetitive: Single Grasping

Pushing & Pulling

Fine Manipulation

3. Patient may use foot/feet for repetitive movement as in operating foot controls: Yes No

4. Patient is able to: Frequently Occasionally Not At All a. Bend

b. Squat c. Climb

d. Twist e. Reach

Other Instructions and/or Limitations Including Prescribed Medications: These restrictions are in effect until or until patient is re-evaluated on (date) (date)

3. He/She is totally incapacitated at this time. Patient will be re-evaluated on

(date)

Physician's Signature Date

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Dear Doctor: You are treating our employee, (Employee’s name) for an injury (he/she) has sustained at work on (date). Getz Fire Equipment considers (Employee’s name) a valuable resource and is committed to providing modified duty within (his/her) functional capabilities as soon as (he/she) is medically able. We have a number of temporary, modified jobs available that have been designed to assist with our injured employee’s rehabilitation until they are physically able to return to their normal full time positions. With your assistance, we would like to enroll (Employee’s name) in our modified-duty program. Enclosed is a Treating Physician’s Return to Work Recommendations Record. Please complete this form and return it to me as soon as possible. (You may either fax it or send it along with the employee) We work closely with our employee’s following their return to ensure they do not exceed their physical restrictions. I would be happy to discuss this with you further, or show you some of our modified duty job tasks if you care to visit. We look forward to (Employee’s name) return. Please contact me if you have any concerns or questions. Thank you. Sincerely, Kathy Thompson

Mailing Address: Shipping Address: P.O. Box 419 1615 SW Adams St Peoria, IL 61651-0419 Peoria, IL 61602-1782

Website: getzfire.com Email: getz@getzfire.com

Ph: (309) 673-0761 Fax: (309) 673-8067

Revised 7/12/2006 Getz Fire Equipment Page 9

RETURN TO WORK LOG The Return To Work Log is an efficient method used to monitor and document the specific tasks your employees are performing while on modified duty.

It helps eliminate potential conflicts should the question arise regarding the employee performing work in excess of their restrictions.

• A supply of forms should be centrally located and provided to each department supervisor/manager.

• Attach a copy of the employee’s restrictions to the log.

• Have employee write name on top of log and the Supervisor write their name.

• Remind employee it is their responsibility to follow the restrictions.

• Remind employee that the restrictions apply both and work and with non-occupational activities.

• Employee and supervisor review all tasks completed each day, indicate any concerns and everyone signs the form.

Revised 7/12/2006 Getz Fire Equipment Page 10

RETURN TO WORK LOG

EMPLOYEE NAME: SUPERVISOR:

Hours Worked

Date In Out

Tasks

Performed

Comments Regarding Employee's

Tolerance of Modified Duty Tasks

Employee

Initials

Supervisor's

Initials

Sunday

/ /

Monday

/ /

Tuesday

/ /

Wednesday

/ /

Thursday

/ /

Friday

/ /

Saturday

/ /

I clearly understand, take responsibility for, and acknowledge the limitations my physician, Dr.

has placed on me while participating in this temporary transitional work program.

Employee Signature Date

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CERTIFIED MAIL – RETURN RECEIPT REQUESTED

EMPLOYEE NAME ADDRESS CITY, STATE ZIP CODE Dear (EMPLOYEE NAME) : We have been informed that you are capable of performing modified work duties by _________________, MD. We have work in our facility within your physical capabilities. This position will be for _____ hours per day, ____ days per week. The rate of pay will be ____ per hour. This work will be available to you beginning ________________, so please report to work on __________ at ______ am/pm. (NAME OF PERSON) is whom you will report to when you arrive at work. I have attached a copy of your Physicians Return To Work Recommendations Record form. Should you have any questions, please call me. Sincerely, Kathy Thompson Attachment

Mailing Address: Shipping Address: P.O. Box 419 1615 SW Adams St Peoria, IL 61651-0419 Peoria, IL 61602-1782

Website: getzfire.com Email: getz@getzfire.com

Ph: (309) 673-0761 Fax: (309) 673-8067