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Topic: WORKERS' COMPENSATION PROCEDURES Date Issued: Nov. 15, 1990

Section: WORKERS' COMPENSATION Date Revised: May 9, 1995

Number: XXI.1.

PURPOSE:

To describe the procedural requirements for the management of the Workers'

Compensation program.

LEGAL BASIS:

Workers' Compensation, a State-mandated program affecting every California

employer, provides statutory financial benefits to any County employee who

is injured or becomes ill due to an incident arising out of and in the

course of employment.

POLICY:

Santa Cruz County is self-insured for Workers' Compensation for the first

$250,000 of any occurrence. Santa Cruz County contracts with Claims Man-

agement, Inc. for the administration of Workers' Compensation claims. All

claims costs within the self-insured retention (S.I.R.) amount are paid by

the County. Excess Insurance above the S.I.R. is obtained through the

County Supervisors Association of California Excess Insurance Authority

(CSAC-EIA).

PROCEDURE:

I. GENERAL INFORMATION

A. Medical Care

County employees will receive all medical treatment necessary to cure

or relieve the effects of a work-caused injury or illness. This in-

cludes all reasonable and necessary related physician's services,

hospitalization, laboratory studies and other appropriate care. These

are paid directly by the County through the claims administrator as a

Workers' Compensation benefit.

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B. Temporary Disability

Employees who cannot work due to work-related injuries or illness,

when the loss of time is confirmed by the treating physician, are

eligible for temporary disability benefits.

1. Employees will not be paid for the first three days of

disability, following the day of injury, unless:

a. they remain off work more than fourteen days, or

b. they are hospitalized overnight, or

c. they work less than a full day on the date they are

injured.

2. Payment continues until the treating physician releases the

employee to return to work. The weekly rate for temporary

disability payments is based on two-thirds of employee's

gross weekly wages to a pre-determined maximum payment set

by State law.

Note: Lost time payments for Safety members of PERS and of

employees in the Detention Officer class series differ from

the above. See Section V.C. of these procedures.

C. Cal/OSHA Reporting Requirements

Risk Management must report every employee death occurring at

work or in connection with work to the California Division of

Industrial Safety (D.I.S.) within 24 hours. Additionally, D.I.S.

must be notified of any work-related injury or illness which

"...requires inpatient hospitalization for a period in excess of

24 hours for other than medical observation, in which an employee

suffers loss of any member of the body or any serious degree of

permanent disfigurement".

In order to meet this legal requirement, departments must notify

Risk Management immediately of any such occurrence. (See Report-

ing Procedures II. below)

D. Employee Claim Form

Effective January 1, 1990, an Employee Claim Form for Workers'

Compensation Benefits must be provided to each employee reporting

a work-related injury. The State has established severe penal-

ties for employers who fail to provide this form to employees on

a timely basis. Packets containing the Claim Form, a Supervi-

sor's Report of Accident Form, a double-sided instruction sheet

with a "Proof of Service by Mail" Form on the reverse, "Facts for

Injured Workers" leaflet and Physician's Certification form

(PER1081A) have been distributed to all supervisors, managers,

and payroll clerks.

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WORKERS' COMPENSATION PROCEDURES Page 3 of 12

II. REPORTING PROCEDURES

A. When an employee reports a work-related injury or illness, the

supervisor or other departmental representative should immediate-

ly complete the Employer section of the Employee Claim form

(leaving line 13. blank) and give it to the employee. The em-

ployee will complete the top portion and return it. The supervi-

sor should then fill in the date received on line 13., detach the

employee (green) copy and give it to the employee, together with

the "Facts" leaflet. The bottom (goldenrod) copy should be re-

tained for the supervisor's records. (See G. 1-4 of this Section

for further processing procedures.)

B. If the employee requires emergency medical attention, it should

be provided immediately, and the Claim form processed afterward,

no later than one working day after the injury.

C. In case of serious injuries, if the employee is not available to

complete the Claim form within one working day, the supervisor or

departmental representative should fill in the Employer section

(leaving line 13. blank), complete the "Proof of Service by Mail"

section on the reverse of the Claim form instruction sheet, and

mail the 5-part form, the "Facts" leaflet and the Physician's

Certification form (PER1081A) to the employee's home address.

The "Proof of Service" form should be hand-delivered to the de-

partmental payroll clerk.

D. On the day that the department learns of the injury, the supervi-

sor or other departmental representative should call Risk Manage-

ment at 454-2240 and state he/she is reporting a Workers' Compen-

sation injury. The following information should be given:

1. name, department and phone number of the reporting party

2. injured worker's name

3. date injury occurred

4. brief description of injury (example - cut finger, left

hand)

5. Did employee get medical attention? (name of doctor or

clinic, if known)

6. Will worker be disabled beyond the date of injury? (if

known)

7. Was Claim form filled out by worker and returned? (or was it

mailed to the worker?)

E. If the injury occurs outside of regular business hours, a message

containing the above information should be left in phone mail on

the 454-2240 line, which has been forwarded to the Personnel

Department phone mailbox.

F. For fatalities occurring at work or serious work-related injuries

occurring outside of regular working hours, the supervisor or

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other departmental representative should call Cal/OSHA at (408)

452-7288 to report the death or injury and give pertinent de-

tails. This should be done as soon as possible after medical

attention has been arranged. (A serious injury or illness is one

which requires hospitalization for more than 24 hours for other

than medical observation, or in which a part of the body is lost

or permanent disfigurement occurs). Risk Management should then

be contacted immediately at 454-2240 and a message left in phone

mail. A follow-up call should be made on the next business day.

G. The following are reporting procedures to be followed in four

different situations:

1. Death of an Employee While at Work

a. If death occurs in a County office or surrounding area,

those first aware of the incident should attempt to

preserve any related evidence at the scene. The names

and addresses of all possible witnesses should be gath-

ered.

b. Notify Risk Management immediately of the death, giving

as may details as are known at the time regarding cir-

cumstances leading to/resulting in the death.

c. The employee's supervisor shall conduct a thorough

investigation of the facts of the incident. If there

is a question about whether the death was caused by

work, the supervisor should confer with Risk Management

prior to completing Workers' Compensation paperwork.

d. If the death appears to be work-related, the employee's

supervisor or acting supervisor must complete a Super-

visor's Report of Accident, mail the Claim form to the

employee's home address, complete the "Proof of Service

by Mail" form and hand-carry both forms to the depart-

mental payroll clerk who should immediately type the

Employer's Report of Occupational Injury/Illness and

forward to Risk Management by messenger. The payroll

clerk should make a copy of the "Proof of Service" for

the department's records, log the injury in the Claim

form Log, and deliver the original to Risk Management.

e. Any facts that may establish that another person or

agency may have directly or indirectly caused the em-

ployee's death should be attached to the Employer's

Report so that third party liability, if any, may be

assessed.

f. If there is any question whether the death is work-

related, this should be noted in a statement attached

to the Employer's Report along with supporting details.

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WORKERS' COMPENSATION PROCEDURES Page 5 of 12

2. Injury/Illness Requiring Emergency Medical Care

Emergency Medical Care applies to injury/illness which is

considered to be potentially life threatening or of such a

traumatic nature as to likely result in undesirable conse-

quences if medical care is not immediate.

a. In these cases, obtaining immediate medical treatment

is the only initial consideration. Employees aware of

such injury/illness of another employee should obtain

emergency medical care, and then notify their depart-

ment as soon as possible. If the injury is life

threatening, the employee should be transported to the

emergency room of the nearest hospital. For non-life

threatening injuries (such as serious cuts, fractures,

sprains), the employee should proceed to the nearest

emergency medical clinic. The supervisor should call

the medical facility to authorize treatment.

b. The employee's supervisor must notify Risk Management

as soon as possible and follow up as appropriate to

monitor the status of the employee. The supervisor

shall take the following actions within 24 hours of the

incident:

1. conduct a through investigation of the facts of

the incident;

2. mail the Claim form, along with the "Facts for

Injured Workers" leaflet and the Physician's Cer-

tification form (PER1081A), to employee's home

address and complete the "Proof of Service by

Mail" form;

3. complete the Supervisor's Report of Accident,

attach the "Proof of Service" form and refer both

forms to the department's payroll clerk to type

the Employer's Report of Occupational Injury/Ill-

ness;

4. attach to the Supervisor's Report any facts that

may establish that another person or agency may

have directly or indirectly caused or contributed

to the injury/illness;

5. if there is any question whether the injury/

illness is work-related, this should be noted in a

statement attached to the Supervisor's Report

along with supporting details.

c. The payroll clerk should refer the typed Employer's

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Report to the appropriate division head or department

manager, together with any attachments, for review and

signature. The payroll clerk should log the injury in

the Claim form Log and then forward the forms to Risk

Management by messenger, within 48 hours of the employ-

ee's initial report. This time frame is necessary

because State Law requires that reports be filed with

the County's claims administrator (located in Sacramen-

to) within five days of the employee's initial report.

(The bottom copy of the Supervisor's Report and Employ-

er's Report and a photocopy of the "Proof of Service"

should be retained for departmental records.)

3. Injury/Illness with Non-Emergency Treatment by a Physician

a. The employee must report the injury/illness to his/her

supervisor as soon as possible to insure supervisor

awareness and documentation of the incident. If the

employee's own supervisor is unavailable, the employee

must report to another supervisor.

b. Upon notification by the employee, the supervisor

should follow procedures on completing the Employee

Claim form outlined at the beginning of this section,

and then refer the employee to the nearest emergency

medical clinic, along with a blank Physician's Certifi-

cation form (PER1081A). (Employees who have previously

provided Risk Management with a written request to use

their own family doctor may do so.) The supervisor

should call the emergency medical clinic to authorize

treatment.

c. The employee shall have the physician complete the

Physician's Certification form (PER1081A) and return it

to his/her supervisor as soon as possible after receiv-

ing medical attention.

d. If the employee is unable to return to work, he/she

should obtain a disability statement from the physician

before leaving the doctor's office, and promptly mail

it (or otherwise see it is returned) to his/her super-

visor. The employee should call the supervisor immedi-

ately to notify them of the disability period and when

the physician expects the employee will be able to

return to work.

e. The employee's supervisor shall complete a Supervisor's

Report of Accident within 24 hours, attach the copies

of the Claim form and deliver the forms to the depart-

ment's payroll clerk to follow procedures outlined in

Section G.2.c. above.

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WORKERS' COMPENSATION PROCEDURES Page 7 of 12

f. Attach to Employer's Report any facts that may estab-

lish that another person or agency may have directly or

indirectly caused or contributed to the injury/illness.

g. If there is any question whether the injury/illness is

work-related, this should be noted in a statement at-

tached to the Employer's Report along with supporting

details.

4. Injury/Illness Not Requiring Treatment by a Physician

The employee must report the injury/illness to his/her su-

pervisor the same day of the occurrence to insure supervisor

awareness of the incident. The supervisor should complete

a Supervisor's Report of Accident and follow procedures for

filling out Claim form within one working day. The supervi-

sor should note in the comments section "no lost time, no

medical treatment". The forms should be referred to the

department's payroll clerk, who will note the injury in the

Claim form log, keep appropriate copies and forward the

white original Supervisor's Report and white and canary

copies of the Claim form to Risk Management. No Employer's

Report is needed for this type of work injury.

H. It is important that injuries not requiring a physician's treat-

ment be reported so that the supervisor can ascertain the cause

and take action to eliminate hazards that could cause more seri-

ous incidents. It is also important to document the injury/ill-

ness so if related complications develop later, there will be no

dispute as to the cause.

III. DEPARTMENTAL RESPONSIBILITIES WHEN AN EMPLOYEE IS OFF WORK

A. The employee's supervisor shall notify Risk Management the same

day he/she becomes aware the employee will not be returning to

work. If the employee's supervisor is not available, the acting

supervisor should make notification.

B. The employee's supervisor shall contact the employee within 24

hours of first knowledge that the employee is off work and on a

periodic basis as appropriate thereafter. The department should

inquire about the employee's health, adequacy of medical care and

prospective return to work date to let the employee know the

department is concerned and cares about him/her.

C. Risk Management should be kept informed of any changes in the

employee's off work status and of any significant employee con-

cerns that have been expressed during the periodic department

contact.

D. The employee's departmental payroll clerk must submit a time card

for the employee no later that 10 a.m. Thursday of the week each

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pay period ends. The payroll clerk shall attach a note listing

all the employee's accrued leave balances (annual leave, vaca-

tion, sick leave, comp time).

E. It is the department's responsibility to see that any period of

disability is documented by a Physician's Certification form

(PER1081A) completed and signed by the treating physician. Cop-

ies of all disability statements should be forwarded to Risk

Management immediately upon receipt.

F. Risk Management will remind the payroll clerk when an injured

employee is close to reaching 160 consecutive hours of leave

without pay due to a work-related injury or illness. It is the

department's responsibility to coordinate with the injured em-

ployee for the completion of appropriate forms and preparation of

paperwork to place employee on Leave of Absence. (See Personnel

Administrative Manual Section XIII.2. Medical Leaves of Absence

Without Pay.)

IV. EMPLOYEE RETURN TO WORK

When an employee who has been off work in connection with a work-re-

lated injury or illness returns to work, the procedures outlined in

the Personnel Administrative Manual Section XIII.2. dealing with Re-

turn from Leave of Absence Without Pay for Medical Reasons should be

followed. In addition, the following items should be addressed:

A. The employee's supervisor must notify Risk Management by phone or

in person, the same day an employee returns to work. Risk Man-

agement must also be informed of any work restrictions.

B. The employee must have a Physician's Certification form

(PER1081A) signed by a State licensed physician releasing the

employee to return to work. The Physician's Certification form

(PER1081A) must indicate any work restrictions, specifying their

duration.

C. The department must insure that all specific restrictions are

understood by the employee and his/her supervisor(s). The em-

ployee and his/her supervisor(s) are responsible for insuring

that all specific work restrictions are adhered to.

D. After initial return to work, should the employee again take time

off related to the original injury/illness, the supervisor will

notify Risk Management the same day by phone or in person. Risk

Management and/or the Workers' Compensation claims administrator

will work with the department in each case to determine what

course of action should be followed.

V. PAYMENTS TO EMPLOYEES

A. Medical Bills

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All employee medical bills resulting from a work-related injury/

illness should be submitted directly to the County's claims ad-

ministrator, Claims Management, Inc., P.O. Box 3042, Sacramento,

CA 95812-3042, Attn: Santa Cruz County Claims Examiner.

Medical bills (including related prescriptions) are paid directly

by the claims administrator. It should be noted that payment of

medical bills will be delayed until after receipt of both the

physician's report and the Employer's Report of Occupational

Injury/Illness by the claims administrator.

B. Temporary Disability

Workers' Compensation payments for temporary disability will be

paid directly by the claims administrator. These may be supple-

mented by use of accrued leave paid by the County Auditor-Con-

troller. In no event will the combined temporary disability and

accrued leave payments exceed the employee's full regular salary.

This section does not apply to Safety members of PERS or to em-

ployees in the Detention Officer class series.

C. Labor Code Section 4850 Paid Leave

This section applies only to the following groups:

1. P.E.R.S. Safety Member Classes:

District Attorney Inspector II/I

Chief District Attorney Inspector

Deputy Sheriff

Sheriff's Sergeant

Sheriff's Lieutenant

Sheriff's Chief Deputy

Sheriff - Coroner

2. Detention Officer Classes:

Sheriff's Detention Officer

Supervising Detention Officer

Detention Sergeant

When an employee in one of the above classes is disabled, whether

temporarily or permanently, by an injury or illness arising out

of and in the course of his/her duties, that person shall be

entitled, regardless of his/her period of service with the Coun-

ty, to leave of absence while so disabled without loss of salary,

in lieu of temporary disability payments, for the period of such

disability but not exceeding one year, or until such earlier date

as he/she is retired on permanent disability pension.

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VI. REPORTING FORMS:

A. Employee's Claim for Workers' Compensation Benefits,

Supervisors' Report of Accident and Employer's Report of Occupa-

tional Injury/Illness (See end of this section for samples of

these forms.)

1. Timetable for Submission of Forms to Risk Management

a. Within 48 hours of a report of a serious injury/illness

requiring emergency medical treatment;

b. Within 48 hours after the employee report of

injury/illness, for other types of injuries.

2. Completion of Report Forms

a. The Employer section of the Employee Claim Form must be

completed by the employee's supervisor, and given to

the employee to complete the top portion. (See begin-

ning of II of this procedure for full description of

claim form procedure.)

b. The Supervisor's Report of Accident must be completed

by the employee's supervisor (not the employee). The

report should be completed using information provided

by the employee.

c. A supplemental statement must be attached to the Super-

visor's Report if circumstances indicate that another

person or agency may have directly or indirectly caused

or contributed to the injury/illness, or if it is ques-

tionable whether the injury/illness is work-related.

d. The Supervisor's Report and copies of Employee Claim

form or "Proof of Service by Mail" are then given to

the departmental payroll clerk, who types the Employ-

er's Report of Occupational Injury/Illness from the

information contained on the Supervisor's Report. The

payroll clerk then logs the injury in the Claim form

log and submits the forms, together with any attach-

ment, to the appropriate division head or the depart-

ment manager, who reviews the material and signs in

signature box on the Employer's Report.

3. Distribution of Report Forms

Distribution of the forms should be as follows:

a. Employee's Claim for Workers' Compensation Benefits

(after employee completes and returns it)

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1. Two copies (white and canary) to Risk Manage-

ment attached to Supervisor's Report (and Employ-

er's Report if medical treatment was received or

work time lost beyond date of injury).

2. Photocopy to department payroll clerk to log in

Claim Form Log and place in employee's departmen-

tal file.

3. Green copy to employee

4. Goldenrod copy retained by supervisor.

b. Supervisor's Report of Accident

1. Top two copies (white and yellow) to Risk Manage-

ment, attached to Employer's Report if medical

treatment was received or work time lost beyond

the date of injury.

2. Pink copy to the department payroll clerk to place

in employee's departmental file.

3. Goldenrod copy retained by the supervisor.

c. Employer's Report of Occupational Injury/Illness:

1. Top three copies sent to Risk Management;

2. Bottom copy to be filed in employee's department

file.

4. Use of the Employer's Report Forms

The Employer's Report of Occupational Injury/Illness forms

are used:

a. to document an employee's claim to an occupational

injury/illness;

b. to document the nature and circumstances of the injury

or illness;

c. as the source of information needed to complete the

Cal/OSHA No. 200 Log and Summary of Occupational Inju-

ries and Illnesses. See Section XX.12. for procedures

relating to this Log.

B. Risk Management sends the original and one copy to the County's

Workers' Compensation claims administrator for review and appro-

priate action. California State law requires that the claims

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administrator must submit the report to the California Division

of Industrial Accidents within five days of the employee's report

to his/her supervisor. To accomplish this, the Employer's Report

of Occupational Injury/Illness must be received by Risk Manage-

ment not later than 48 hours after the employee's initial report.

C. If an injury or illness is potentially life threatening or causes

death, it must be reported initially by telephone to Risk Manage-

ment as soon as possible.

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