What to Do If An Injury Occurs at

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What to Do If An Injury Occurs at Work UCOP Goleta Prepared and Developed

What to Do If An Injury Occurs at Work UCOP Goleta Prepared and Developed by Erin Choi, UCOP Student Intern

Injury at Work: Instructions on UCOP Webpage • UCOP Human Resources: – http: //hrop.

Injury at Work: Instructions on UCOP Webpage • UCOP Human Resources: – http: //hrop. ucop. edu/ • Employee – Injury at Work: – www. ucop. edu/humres/workers_compens ation/employee/injury. html • Supervisor/Manager – Injury at Work: – www. ucop. edu/humres/workers_compens ation/supervisor/injury. html

What to Do If an Injury Occurs at Work (Employees) If injured at work:

What to Do If an Injury Occurs at Work (Employees) If injured at work: – Report incident to your supervisor immediately – Promptly obtain proper medical care If emergency care is needed: – Go to nearest emergency room – Report injury to your supervisor as soon as possible – For follow up care, go to UCOP’s Occupational Health Center or your designated physician

UC Designated Occupational Health Facilities - Goleta • Webpage: – http: //www. busserv. ucsb.

UC Designated Occupational Health Facilities - Goleta • Webpage: – http: //www. busserv. ucsb. edu/workerscompensation/mtaf. htm • Occupational Medicine Center - Sansum/Santa Barbara Medical Foundation Clinic (SSBMFC) – 101 S. Patterson, Santa Barbara 805 -898 -3311 Hours: Monday – Friday 8 AM to 6 PM • Urgent Care/Hitchcock Branch - Sansum/Santa Barbara Medical Foundation Clinic (SSBMFC) – 51 Hitchcock, Santa Barbara Hours: Saturday – Sunday 805 -563 -6133 9 AM to 6 PM USE ONLY WHEN PATTERSON OFFICE IS CLOSED

UC Designated Emergency Medical Facilities - Goleta • Goleta Valley Cottage Hospital – 351

UC Designated Emergency Medical Facilities - Goleta • Goleta Valley Cottage Hospital – 351 S. Patterson Ave. , Santa Barbara 805 -967 -3411 Hours: Every Day, All Hours • Santa Barbara Cottage Hospital – Pueblo at Bath, Santa Barbara 805 -682 -7111 Hours: Every Day, All Hours

Medical Treatment - Employee’s Personal Care Physician • Employee can designate personal care physician

Medical Treatment - Employee’s Personal Care Physician • Employee can designate personal care physician – Must have completed pre-designation form – http: //www. ucop. edu/humres/workers_compe nsation/employee/pre_form. pdf • Employee should discuss with personal care physician – Physician must agree to treat employee in accordance with California Workers Compensation Laws

What To Do If an Injury Occurs at Work (Employees Continued) • If the

What To Do If an Injury Occurs at Work (Employees Continued) • If the treating physician certifies you for disability - Provide your supervisor with medical certification of: – Any and all disability leave dates; – Any and all future changes in disability leave dates • It is your responsibility to keep your supervisor informed

Injury at Work Supervisors – Three Immediate Actions Arrange medical care for the employee

Injury at Work Supervisors – Three Immediate Actions Arrange medical care for the employee – If employee has signed the pre-designated physician form on file; the employee can go to their physician – Or refer employee to one of the UCOP Occupational Health Centers and contact HR Benefits Office Complete Incident Report – Section 2 – Employee completes Section 1 – Treating physician completes Section 3 Complete Employer’s Report of Occupational Injury/Illness Form (5020) http: //www. ucop. edu/humres/workers_compensation/edb_ prep/procedure_2. pdf

UCOP Incident Reports • Approximately 45 Incident Reports submitted every year • Why complete

UCOP Incident Reports • Approximately 45 Incident Reports submitted every year • Why complete an Incident Report? – Documents the incident – Differentiate first aid/minor injury incidents from workers compensation-type injuries – Helps to significantly reduce UC’s workers compensation costs – Human Resources & Department Safety Officer opportunity to review/investigate all incidents

University of California INCIDENT REPORT Section #1 EMPLOYEE INFORMATION: Employee Completes This Section •

University of California INCIDENT REPORT Section #1 EMPLOYEE INFORMATION: Employee Completes This Section • Section 1 of the Incident Report – Completed by the employee Campus: ___________________ Last four digits of social security number: ________ Name PRINT: ________________________________Sex _ Male _ Female Home Address: _________________ City: _____________Zip: _______ Home Phone: __________________ Work Phone: ___________________ Department: _______________ Job Title: ________________________ Work Hours: ______________ Hours Worked per Week: __________________ Employment Type _ full-time _ part-time _ regular _ temporary _ seasonal _student _ volunteer _ appointment Do you have other employment? _ yes _ no If so, where __________________________ INCIDENT INFORMATION Date of Incident ___________ Time of Incident: ____________ Address/Bldg, name & room # of incident: ______________________________ Zip Code _____________ State all parts of body and type of injuries involve (e. g. bruised right elbow) ______________________________________________________________________________________________ Describe how incident occurred: _______________________________________________________________________________________________ Was incident reported? _ yes _ no If “yes” to whom? ___________________________ Date reported: ________________ Were there witnesses? _ yes _ no _ unknown Name of Witness #1 (First and Last): _________________________________ Witness #1 Phone Number: _____________________________________ Name of Witness #2 (First and Last): _________________________________ Witness #2 Phone Number: _____________________________________ Is this a new injury? _yes _no If “yes” indicate date, If “no”, please indicate date of original injury ________________________________________________ INITIAL MEDICAL TREATMENT Was treatment received for this injury? _ No medical treatment- reporting only _ Declined treatment at this time _ Treatment was/will be provided Treatment was provided by: _ Self _ Occupational Health _ Emergency Room _ Other (please specify below) If treatment was provided, name and location of medical provider. Name: ______________________ Address____________________ Phone: _____________________ I, the injured employee, herein certify the information above is true and to best of my knowledge Date: ____________ Signature of Employee: __________________________

Incident Report Form Section #2 • Non-emergency situation: – Supervisor completes Section 2 first;

Incident Report Form Section #2 • Non-emergency situation: – Supervisor completes Section 2 first; then – Incident Report given to employee to complete Section 1 • Incident Reports – Handed/mailed to employee within 1 day of knowledge of on-the-job injury/illness – If mailed – Use proof of service mail delivery form Section #2 SUPERVISOR COMPLETES THS SECTION: Supervisor Name: ______ ___email address_______ Work Phone: __________________ Describe how the employee was injured. _______________________________________________________ Did employee lose time from work? _yes_ no _unknown If ‘yes’ First day of lost time Was the Employee paid for the full date of injury? _ yes _ no Date Employee returned to Work. _____________ Was there equipment involved? _yes _ no If answered “yes” what was the equipment What action will be taken to prevent recurrence? ____________________________________ Other Comments: ________________________________________________ Date: ______Signature: ______ Title: ________

Incident Report Form Section #3 • Medical care provider – Completes Section 3 of

Incident Report Form Section #3 • Medical care provider – Completes Section 3 of the Incident Report (If medical care is required) Section #3 MEDICAL PROVIDER COMPLETES THIS SECTION: _________________________________ Medical Provider - What treatment was provided for this injury (check one) _ First Aid _ Medical Treatment Return To Work: Can Return immediately _yes _ no If no, date employee can return to work _____________ _Full duty _ Restricted work Employee can return to work with these specific restrictions: _________________________________________________ _________ Estimated period of absence: ________ to_________ Next appointment: ______ Date: _______ Signature: ________________ Title: ___________________________________________ Note: If, initially, first aid is rendered but at a later date treatment beyond first aid is required, please contact the Workers’ Compensation Department immediately and initiate the filing of a workers’ compensation claim. Seeking first aid treatment and completion of this report does not waive the employee’s right to file a workers’ compensation claim and seek benefits in accordance with statutory workers’ compensation laws. A physician who treats an injured employee is required to file a 5021 (“Doctor’s First Report of Injury”) with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work.

Completed Incident Report • Placed in employee’s workers compensation file • Copy to UCOP

Completed Incident Report • Placed in employee’s workers compensation file • Copy to UCOP Benefits Office: – Hand delivered; or – Fax (510)217 -6062 • Copy to Department Safety Officer: – Investigation and recommend corrective measures – Prevent similar incidents in the future

Employee Loses Time from Work (Supervisors) • Contact Employee Dept. Benefits (EDB) Preparer or

Employee Loses Time from Work (Supervisors) • Contact Employee Dept. Benefits (EDB) Preparer or Department Personnel Assistant (DPA) for: – Family Medical Leave Act (FMLA) Procedures and Eligibility Criteria • Notify UCOP Return to Work/Vocational Rehabilitation Program. – Reduce Lost Workdays: • Provide medically appropriate modified work during the transitional stages of your employee’s medical recovery – Call Roger Howland at (510) 987 -0893 for: • Assistance/consultation in designing Transitional/Modified work – The day employee returns to work: • Notify UCOP HR Benefits Office to prevent overpayment of disability benefits.

Injuries • Call 9 -911 (Emergency) • Call UCOP Benefit Services as soon as

Injuries • Call 9 -911 (Emergency) • Call UCOP Benefit Services as soon as possible to report the serious injury: – – (510) 987 -0123 – Customer Service Line (510) 987 -0819 – Anne Buckland (510) 987 -0816 – Leslie Lyons (510) 987 -0893 – Roger Howland • Remove the equipment from service (If applicable) • Tag the equipment for identification (If applicable) • Contact Roger Howland at (510) 987 -0893 to initiate an inspection • For additional assistance – Contact UCOP Benefit Services Office