1

WORKERS’ COMPENSATION

PROCEDURES FOR NAF

SUPERVISORS

EMERGENCY KIT

2

TABLE OF CONTENTS

GENERAL INFORMATION 3

SUPERVISOR RESPONSIBILITIES 3

EMPLOYEE RESPONSIBILITIES & BENEFITS 4

REDUCTION OF COSTS 4

"IN A NUT SHELL" 5

INSTRUCTIONS FOR SUBMISSION OF WC FORMS 6

DEFINITIONS OF TERMS 7

DEFINITIONS OF FORMS 8

FORMS WEBSITE 8

EXAMPLE OF FORMS 10

EMPLOYEE WORKERS' COMPENSATION INFORMATION SHEET 21

56th FIGHTER WING

MISSION STATEMENT:

“Train the World’s Greatest F-16 Fighter Pilots and Maintainers, while

deploying Mission Ready Warfighters.”

VISION STATEMENT:

“Developing Airman for America’s Air Force”

56th FORCE SUPPORT SQUADRON MISSION:

“Provide exceptional combat readiness through quality of life and mission

enhancing programs.”

VISION STATEMENT:

“First Class Service support….Period!”

3

GENERAL INFORMATION

Under the Longshore and Harbor Worker’s Compensation Act (as amended by the NAFI), all Air Force

NAF employees, (does not cover off-duty military, contract workers, and volunteers), are covered under guidelines for Workers’ Compensation for Air Force civilian NAF employees contained in AFI 34-308, Nonappropriated Fund Employees Workers’ Compensation Program. This is a self-insured and self-administered program regulated by the Department of Labor. This program provides workers’ compensation benefits for injures or illness which arising out of and in the course and scope of employment. The benefits due to an AF NAF civilian employee who substantiated a job-related injury or illness may include disability payment, medical expenses, or death benefits. This enclosed is provided to help maintain accurate reporting procedures of Workers’ Compensation claims as well as reduce the resulting costs of these claims. In this package, you will find the information, procedures, and forms necessary to process all worker’s compensation claims.

SUPERVISOR RESPONSIBILITIES

IAW AFM 34-311, it is the supervisor’s responsibility to brief employees on procedures they must follow in reporting work-related injuries and illnesses.

Brief and train employees on the proper procedures they must follow in reporting work-related injuries and illnesses. At first knowledge of an alleged job-related injury or illness, supervisor will arrange and provide necessary and timely assistance and all necessary forms. Supervisors will ensure all forms are completed

accurately, signed, and originals forwarded to the HRO in a timely manner. Contact the squadron Ground Safety Officer and the HRO In the case of an employee’s death or in the event of a seriously disabling injury or illness. Supervisors will make every attempt to arrange for light duty consistent with employees treating physician’s release. Instruct and ensure injured employees submit all bills, forms, work restrictions, doctor’s notes, etc. to the supervisor or the Human Resources Office. Be specific when completing documents such as date and time, location and how accident occurred. Include which body part, extremity, or joint was injured. Obtain written statements, names, address, and telephone number of any witness. Ensure employee follows all doctor’s instructions.

Ensure the Department of Labor Form LS-242, Notice to Employees are posted and maintained in

customary bulletin board areas. Upon an employee’s request for medical care due to an alleged

injury, supervisor completes part A of Form LS-1, items 1 through 13 and sends this form with the

employee to the medical treatment facility of their choice. The supervisor must inform the Human

Resources Office and the squadron safety officer of all on the job injuries.

Supervisors must work directly with the HRO on all matters pertaining to workers’ compensation benefits

and promptly inform the HRO of any change in the employee status or work schedules. Keep in mind that you should maintain close contact with your employee who is losing time from work. Let them know you are concerned!

4

EMPLOYEE RESPONSIBILITIES & BENEFITS

It is the employee’s responsibility to report any injury or illness, no matter how slight, to their immediate supervisor. An injured or ill employee is responsible for notifying their supervisor of a “return to work” date or a “return to light duty” date with any medical restriction. The injured employee must attend all medical appointments and must inform their supervisor on a regular basis of their condition and any change in status. The employee turns in all bills, forms, work restrictions, Doctor’s notes, etc. received by them to their supervisor or the Human Resources Office. The employee is entitled to receive Workers’ Compensation benefits when absent from work. The compensation benefit will not include payment for the first 3 days the employee is out of work, unless the period of disability exceeds 14 days. In that event, the first 3 days are paid retroactively. Employees losing time from work can expect a benefits payment every 14 days. An injured employee with a Regular employment category may also choose to have the compensation benefits supplemented by sick leave, but not to exceed 100% of employee’s base wage. A completed OPM Form 71, Request for Leave or Approved Absence must be completed by the employee with the dates of lost time and annotate following remark: “Supplementation of any workers’ compensation benefits due” and sends the approved OPM Form 71 to the HRO. Call the HRO for guidance if the employee requests this.

REDUCTION OF COSTS

Your assistance is needed to enable employees to return to work as soon as their physician gives them approval and ultimately to help reduce the compensation costs to our activities. Supervisors must be willing to accommodate employees with suitable light or limited work assignment, to include: a. part-time work b. light duty work to accommodate medical limitations and/or restrictions c. assign the employee to duties that he/she can perform Don’t deny the employee a placement except for the most compelling reasons. If you must deny placement of a medically approved, limited duty employee, you must document by memo the reason and forward to the HRO. Remember, the longer the person is out of work, the harder it is to get them back to work. You can reduce the claim by up to 30% if you get them back to work right away, even if its only light duty. It is the supervisor’s responsibility to document any evidence of fraudulent or malingering claims. Ask questions, make detailed notes, and have witnesses write statements and contact the HRO. Your role in reducing compensation costs is critical. The AF has an Early Intervention Case Management Program which is designed to assist NAFI’s and the injured employee following a work-related injury. If an employee has lost time, a Nurse Case Manager (NCM) may be assigned.

5

“IN A NUT SHELL”

Upon notification of an on the job injury or illness, supervisor will issue to the injured employee the

following: Form LS-555-Privacy Act of 1974 Notice; Employee Information Sheet, Form LS-1,

Request for Examination and/or Treatment (with Part A, items 1-13 completed); Form LS-201, Notice

of Employee’s Injury or Death; and AF Form 786, Patient’s Authorization for Release of Medical

Information. Refer the injured employee to the medical treatment facility of their choice. Do not give more than one Form LS-1 to an employee or medical service provider for any single injury. If the claim in questionable, check item 7b on LS-1.

For the initial assessment/treatment, employees may seek to use any medical treatment facility to include the base clinic, or a doctor of their choice. Any subsequent medical treating physician will remain the treating physician for the life of the injury. The injured employee has the option to seek medical attention. If the employee refused medical attention, have the employee provide a written statement indicating they refuse medical attention at this time (may be written on LS-1). This does not mean the employee may not seek medical attention at a later date. Employee may use Form LS-204 for to seek future medical attention related to the same on the job injury.

Contact the HRO and Squadron Safety Office to report an on the job injury.

Submit all ORIGINALS to HRO Form LS-1, Request for Examination and/or Treatment (after medical

treatment facility completes part B); Form LS-201, Notice of Employee’s Injury or Death; Form LS-202,

Employer’s First Report of Injury or Occupational Illness; AF Form 786, Patient’s Authorization for

Release of Medical Information; AETC Form 435 On or Off Duty Ground Mishap Report.

For each and every follow up treatments, provide employee with Form LS-204, Attending

Physician’s Supplementary Report.

All original forms, doctors’ notes, etc. are to be returned to the HRO.

Provide HRO with a copy of the time cards.

Maintain contact with HRO until employee returns to duty w/out restrictions.

6

INSTRUCTIONS FOR SUBMISSION OF WORKERS COMPENSATION FORMS

TIME FRAME (SUSPENSES) FORM COMPLETED BY FORWARDED TO

Date of injury or soon after if it is an emergency

LS-1, Request for Examination and/or Treatment

Only if deemed necessary –

Call HRO for Approval

Supervisor completes

FRONT page

Employee takes to 1st Dr visit then

returns to HRO after Dr completes

or w/ Dr notes

Physician - BACK Page

Date of injury or soon after LS-202, Employee's First Report of Injury or

Occupational Illness Supervisor HRO

Date of injury or soon after AETC FORM 435 Mishap Data Worksheet Supervisor Squadron Safety Officer

Copy to HRO

Date of injury or soon after AF Form 786, Patients Authorization for Release

of Medical Information Employee READS & SIGNS HRO

Date of injury or soon after

LS-555 U.S. Department of Labor Employment

Standards Administration Office of Workers'

Compensation Programs

Read ONLY HRO

IF EMPLOYEE DECLINES MEDICAL ATTENTION AT TIME OF INJURY, HAVE THEM SIGN THE DECLINATION OF MEDICAL ATTENTION FORM.

Date of injury or soon after

LS-201, Notice of Employee's Injury or Death OR

written statement EMPLOYEE ONLY HRO

LS-201 IS NOT TO BE TYPED

If someone other than the employee completes the LS-201 and employee goes to the Dr, the claim will be denied by WC and employee will be responsible for the Dr visit.

We are dealing with the DOL and it's a crime for anyone other than the injured party to complete the LS-201. If employee is unable to complete the LS-201 form due to

not being able to read or write in English or is physically unable due to incapacitating emergency, the supervisor can write a statement on behalf of the employee on a

separate sheet of paper and write "written for (employee name) due to (give reason)" and sign (supervisor name and title).

FOR FOLLOW-UP ONLY

Within 24 hours of employee's return to work

LS-204, Attending Physician's Supplementary

Report of Accident Physician

HRO Form is for follow-up

appointments ONLY FOR FOLLOW-UP APPT ONLY

Within 24 hours of employee's return to work LS-210, Employer's Supplementary Report of

Accident Supervisor HRO

7

DEFINITIONS OF TERMS

(1) Injury - Accidental injury or death arising out of and in the course of employment and such occupational

disease or infection that arises naturally out of such employment, or as naturally or unavoidably results from such

accidental injury.

(2) Disability - Incapacity because of injury to earn the wages in which the employee was receiving at the time

of injury.

(3) Compensation - The money allowance payable to an employee or his or her dependents as provided by the

applicable compensation law, and includes funeral benefits provided by such law.

(4) Compensable Injury – Injury that occur while the employee is within usual occupation.

(5) Occupational Disease – a disease as a result of a working condition.

(6) Non-Compensable Injury – Pre-existing condition, injuries involving third parties, stress claims.

(7) Disability Benefit – The benefits due an employee injured in a job-related accident or illness.

(8) Temporary Total Disability (TTD) Benefits - The compensation payable while an employee is totally

disabled on a temporary basis, usually 2/3 of the AWW.

(9) Temporary Partial Disability (TPD) Benefits - The compensation payable while an employee is

temporarily unable to earn the average weekly wage earned before the injury, usually 2/3 of the AWW.

(10) Permanent Total Disability (PTD) Benefits - The compensation due an employee who is permanently and

totally disabled, usually 2/3 of the AWW.

(11) Permanent Partial Disability (PPD) Benefits - The compensation due an employee according to a schedule

for the loss of use of a portion of the body or that which results in partial loss of wage earning capacity that is

permanent in nature, usually 2/3 of the AWW.

(12) Day - For the purpose of this program, the term “day” always refers to a calendar day.

(13) Average Weekly Wage (AWW) - The AWW is weekly average over the gross wages of 52 weeks prior to

the injury. Usually 1/52 average annual rate of earnings - or one week’s average earnings.

8

DEFINITION OF FORMS

The following list is a summary of the basic forms. Additional forms may be needed depending on the nature and extent of the injury. Sample and blank forms are enclosed in this package. All yellow highlighted areas indicate areas to be filled out by the supervisor.

FOR EACH INJURY OR DISEASE ALLEGED BY THE EMPLOYEE, EACH OF THE

FOLLOWING FORMS IS REQUIRED:

Form LS-1, Request for Examination and/or Treatment: On an employee’s request for medical care due to an injury, supervisor completes items 1 through 13. This form sent with the employee to the physician or medical facility. The attending physician completes the back of the LS-1. In an emergency, the LS-1 should be sent to the treating physician or medical facility within 24 hours. Do not give more than one Form LS-1 to an employee or medical service provider for any single injury.

Form LS-201, Notice of Employee’s Injury or Death: The employee must complete this form. It is to be submitted to the HRO within 7 days from the date of injury. One form per alleged injury.

Form LS-202, Employer’s First Report of Injury or Occupational Illness: This form is filled out by the supervisor and forwarded to the Human Resources Office within 24 hours of knowledge of injury or illness. One form per alleged injury.

AF Form 786, Patient’s Authorization for Release of Medical Information: This form is signed by the employee and should be submitted to the HRO within 5 days from the date of injury. One form per alleged injury.

AETC Form 435 On or Off Duty Ground Mishap Report: This form must be filled out by the supervisor and submitted to the squadron Safety Officer within 24 hours from the time of injury. One form per alleged injury.

Form LS-204, Attending Physician’s Supplementary Report: To be completed by the physician for each additional appointment. This form is used to document medical status and /or authorization to return to work.

Form LS-210, Employer’s Supplementary Report of Accident or Occupational Illness: This form will be filed each time the injured employee has returned to work and later becomes disabled for work due to the same injury. Please keep the HRO informed of additional lost time due to injury.

Form LS-242, Notice to Employees: This form should be signed by the HRO and posted on the bulletin board.

Form LS-555, Privacy Act of 1974 Notice: Provide this form to your employee if they are injured and need medical treatment. One form per alleged injury.

Employee Information Sheet: Please provide a copy to the employee. This form is designed to brief the injured employee on the proper procedures to be followed. One form per alleged injury.

9

FORMS WEBSITE:

http://lukeevents.com/HRO/NafSupervisory.html

FOR EXAMPLE OF FORMS,

SEE ATTACHMENTS THAT FOLLOW

**USE “INSTRUCTIONS FOR SUBMISSION OF WORKERS COMPENSATION FORMS”

ON PAGE 6 ABOVE FOR PROPERLY COMPLETING THESE FORMS**

10

11

12

13

14

15

16

17

18

19

20

21

EMPLOYEE INFORMATION SHEET

WORKERS’ COMPENSATION

CLAIM PROCEDURES:

1. ___ When injury occurs, NOTIFY your supervisor immediately.

2. ___ You may seek medical treatment from a physician or medical facility of your choice. At the time of

your initial Dr visit, you must inform provider this is a Workers Comp and provide the LS-1, Request for

Examination, given to you by your supervisor. Your supervisor will have you read the LS-555, U S

Department of Labor and sign the AF Form 786, Authorization for Release of Medical Information.

Your Supervisor will also give you an LS-201, Notice of Employee’s Injury or Death. That is the only

LS form that is to be completed by you in your own words. This form is NOT to be typed!

3. ___Pre-authorization is required for any changes whether it be physician or in treatment facility. Contact the HRO if you have any questions.

4. ___ Lost time of more than 3 days may result in the assignment of a caseworker. The caseworker will work with you and the physician to ensure proper medical treatment is being provided.

5. ___ An LS-204, Attending Physicians Supplementary Report, is to be used for follow-up visits or if you did not seek medical attention when injury first occurred. Physician completes this form to provide an update on your medical status.

6. ___You must stay in contact with your supervisor and the Human Resources Office.

7. ___ DO NOT: Pay Dr visit or any medical bills related to your work injury via personal insurance, cash, check, or credit card.

8. ___ DO: Bring all bills, doctor’s notes, and forms to the HRO or send them to WC Insurance Carrier address listed below.

FAILURE TO FOLLOW ESTABLISHED PROCEDURES COULD RESULT IN

NON-PAYMENT OF COMPENSATION. Employee: Date: __________________

HR Assistant: Date: ____________________

=============================================================================

Employer: WC Insurance Carrier – Billing address

56 FSS/FSMH AIR FORCE INSURANCE FUND

7383 N Litchfield Rd Ste 3090 HQ AFSVA/SVXBW

Luke AFB, AZ 85309-1566 2261 Hughes Ave, Ste 156

Lackland AFB, TX 78236-9852