1. Workers’ Compensation
UCLA Health System

2. Who is eligible?
Career, casual, Per Diem employees are covered from the first date of employment
Vanpool injuries
Non-UCLA employees are covered by their respective employers, e.g. Traveler’s, Registry, other temporary workers
Volunteers

3. Initial Employee Contact
Was this injury work related?
If the employee believes it was work-related or is unsure, provide Workers’ Compensation forms and direct the employee to seek immediate medical treatment at either Occupational Health Facility or the UCLA Emergency Department
Employee should tell the UCLA Emergency Department that they are a UCLAMC employee and that they are being treated for a work-related injury
Follow all procedures for a leave of absence
Where to send the employee for treatment?
Employee should be seen by Occupational Health Facility or the UCLA Emergency Department for the first 30 days

4. Cal-OSHA
In case of Serious Injury or DEATH or if an employee is hospitalized: Page the Health System Safety Department pager immediately or call the Campus 24-hour call-in phone number EH&S Hotline: Call Health System Safety Department (310) for any follow-up OSHA requires notice within 8 hours of Serious Injury Serious Injury is: Death Amputation Concussion Crushing injury Fracture Burn Laceration with stitches or significant bleeding Hospitalization beyond Observation

5. WHEN AN EMPLOYEE IS INJURED ON THE JOB...
Provide the employee with:
A completed Workers’ Compensation Claim Form (DWC-1) and Notice of Potential Eligibility
This form must be provided within 1 working day of notice that an injury or illness has occurred as mandated by California state law. (Exception: First Aid incidents)
2. A completed UCLA Incident Report and Referral for Medical Treatment
3. Workers’ Compensation Information Sheet
(SEE HANDOUT FOR LINE BY LINE INSTRUCTIONS)

6. WHAT TO DO WITH THE PAPERWORK?
Please review and complete all lines. Sign where appropriate.
The person to whom the injury is reported should sign all forms where indicated
Department keeps one copy for department records.
If notification was by phone, mail the form to the employee. Certified mail is advisable as proof of mailing.
Immediately:
FAX a copy of the completed form to the WC FAX line Health System HR or
to or
CALL 877-6UC-RPRT ( ) with the information on the form (see Step #5)
Employee keeps one copy of completed form.
Send all other copies of the form immediately to Health System HR for further distribution.
Notify Health System HR Workers’ Comp x40500 as soon as you know an employee has been taken off work. 6

7. WORKERS’ COMPENSATION PROCESS
Employee notifies supervisor that a work-related incident has happened. Supervisor provides UCLA Incident Report and Referral for Medical Treatment form and directs Employee to Occupational Health or the Emergency Medicine Center for medical treatment. Medical Treatment is provided. Medical provider completes a Work Status slip. Employee gives Work Status slip to Supervisor immediately. IF EMPLOYEE WAS SEEN AT THE EMERGENCY ROOM, direct employee to follow-up at UCLA Occupational Health. If treatment is beyond First Aid - Employer provides Workers’ Compensation Claim Form (DWC 1) within 1 working day of injury or knowledge of injury - Employee signs Workers’ Compensation Claim Form (DWC 1) and returns it to Department or Health System HR

8. Claims Process
Sedgwick CMS (Third Party Administrator or TPA) makes 3-point contact: with Employee, with Supervisor, and with Medical Provider
Return all phone calls from Sedgwick CMS as soon as possible.
Employer may investigate an incident. The law allows up to 90 days to delay a decision on compensability. If the claim form was provided and returned timely, medical treatment will be provided up to $10,000 during the decision process
TPA reviews the claim and determines what benefits the employee should receive. TPA notifies the employee by mail and by phone whether claim is accepted, delayed, or denied.
If the injury is delayed or denied and the employee is taken off work by a medical provider, employee should file for disability benefits.
COMPLETE THE ONLINE LEAVE OF ABSENCE NOTIFICATION ON THE HR WEBSITE
If the injury is approved as work related and the employee is taken off work by a medical provider, the employee will receive a temporary disability check from TPA.
Health System HR WC contacts the employee about WC Options via phone or letter to the employee and also notifies the department EDB preparer. 8

9. Work status, work status, work status
Work status, work status, work status! Part One – Temporary Restrictions
Department is responsible for their employee --
Employee must provide manager/department with updated medical disability slips prior to returning to work and throughout the leave.
WHEN THE MEDICAL PROVIDER DETERMINES THAT THE EMPLOYEE HAS TEMPORARY WORK RESTRICTIONS –
OHF or Workers’ Compensation Provider gives the employee a work status slip with any medical restrictions and the approximate duration
Employee immediately gives work status slip to supervisor
Supervisor finds temporary transitional modified duty assignment compatible with medical restrictions for up to 90 calendar days
Employee should have restrictions updated by OHF or Workers’ Compensation Provider within 45 calendar days or earlier if appropriate.
If the department/supervisor does not have modified duties available, supervisor must contact the Return to Work Coordinators for possible placement elsewhere
If the employee refuses the assignment all temporary disability payments may cease
If employee feels at any time that he/she cannot work due to the work-related injury, direct employee back to their Workers’ Comp medical provider immediately to get medical certification of time off.

10. Important Information
Employees should be paid for the time at OHF/EH and/or the EMC (to complete the work shift.) Charge hours to Home Cost Center Employees must use SL for any time at off-site (non-OHF/EH or EMC) appointments, and for time taken for therapy, diagnostic appts Employee may return to temporary work on a modified work schedule or modified duties at any time. Charge actual Modified duty hours worked as ‘Modified Duty Workers’ Comp’and to the Return to Work Cost Center.

11. Who is eligible to use Cost Center/Paycode?
Open WC claim
Work restrictions are:
Temporary AND
Restrict one or more regular job duties (performed at least once weekly) and/or at least one essential function of the job AND
Documented by Medical Provider with a start and end date to the work restrictions
Employees working in a modified assignment related to a non-work related injury or illness are not eligible to utilize these cost centers.

12. RTW Cost Center/Paycode Procedure
Determine if the employee meets criteria. Health System HR/Return to Work coordinators will provide requesting manager/supervisor with the cost center number.
Record the hours worked by the employee on HBS using pay code MDH ‘Modified Duty Workers Comp’ when the hours meet the above criteria for the dates indicated on the work status note
Perform ‘Lookup’ function for the cost center and charge the hours to the appropriate Modified Duty Cost Center
BOTH the pay code and the Cost Center must be used together

13. Contacts for Return to Work Program
Contact Health System HR Workers’ Compensation/ Return to Work coordinators to confirm employee meets eligibility criteria
Health System Human Resources WC
Mark Briskie
Cynthia Vazquez
Ingrid Garcia
Return to Work Coordinators
Mark Briskie
Suzanne Bleibtreu

14. Leave of Absence Procedure – 3 day Waiting Period
If the employee is taken off work completely by the Workers’ Comp Medical Provider, a 3-day waiting period may apply before WC benefits are paid -- The employee must use his/her sick leave for first three (3) calendar days of the leave only. Employee may request the use of VAC/HOL/COMP if wishes to receive full pay for the 3-day waiting period. If the employee does not have enough sick leave to cover the 3-day waiting period, the employee is entitled to receive 80% of his/her regular salary through the 80%Extended Sick Leave benefit. Notify Health System HR WC if the employee does not have enough sick leave and wants to access this benefit. Record no sick leave/vacation on timesheet after waiting period.
3-day Waiting Period --
For 12-hour employees, up to the first 24 scheduled work hours within the first 3 calendar days

15. Leave of Absence Procedure – Beyond Waiting Period
If the employee’s leave continues past the 3-day workers’ comp waiting period, direct the employee to submit an online Leave of Absence Notice at the Health System HR website
Employee can also find additional information regarding the WC leave of absence.
Employee should review the COMPARISON OF PAYMENT OPTIONS and contact Human Resources, Workers’ Compensation coordinator Cynthia Vazquez/Ingrid Garcia, at (310)
WC leave may qualify employee for FMLA leave
If the employee is eligible for FMLA, employee will be on a FMLA leave first, then a WC leave if claim was approved
Online Leave of Absence - Workers’ Compensation Pending
Indicate the last day on pay status using sick leave (or other requested accruals) for the 3-day Waiting Period only
the 4-digit leave code that is generated to the HR Representative to begin the process
Notify EDB preparer as you receive updated work status slips from the Medical Provider throughout the course of treatment so that HR Representative can update Leave of Absence
Notify EDB preparer when the employee returns from leave so HR Representative can update and close the Leave of Absence file 15

16. WC Options – to supplement WC benefits
This process is manual and handled through the HR Rep, Payroll and Health System HR offices.
This significantly impacts the employee’s health and welfare benefits. Please have the employee review and contact HS HR Workers’ Comp unit to elect a WC Option.
Option 1
Employee elects to receive only the workers’ comp TTD check
Employee will be billed for health and welfare benefits as applicable
Option 2
Employee elects to use sick leave only to supplement the workers’ comp TTD check
Health and welfare benefits contributions are taken on regular paydays
Option 3
Employee elects to use sick leave and vacation time to supplement the workers’ comp TTD check
Leaves must be updated regardless of which WC Option is chosen

17. Work status, work status, work status
Work status, work status, work status! Part Two – Permanent Restrictions
Department is responsible for their employee --
Employee must provide manager/department with updated medical disability slips prior to returning to work and throughout the leave.
WHEN THE TREATING PHYSICIAN DETERMINES THAT THE EMPLOYEE HAS PERMANENT WORK RESTRICTIONS WHICH MAY AFFECT EMPLOYEE’S ABILITY TO PERFORM ALL OR PART OF HIS/HER JOB DUTIES –
Contact the Employee Disability Manager Mark Briskie immediately to advise of the permanent work restrictions.
Consider whether you can permanently modify the employee’s job duties to accommodate the restrictions OR
If there is permanent alternate work in the department to accommodate the restrictions
Document all discussion with employee regarding accommodation
An offer of medically appropriate work must be sent to the injured employee within 30 days of the termination of TD payments.
Employees may use any available accruals to return to pay status while accommodations are discussed 17

18. Injury Prevention resources
Health System Safety
SAFETY INSPECTIONS/TRAINING ERGONOMIC EVALUATION
ACCIDENT INVESTIGATION COORDINATION
Erik Eggins
phone fax PAGER 90248
Ergonomic Evaluation Request Form
on HR website

19. Directory
SEDGWICK CMS P.O. Box Lexington KY Mail code Phone Fax CAMPUS PAYROLL UCLA Wilshire Center, Suite 620 MC Phone Fax UCLA HEALTHCARE PAYROLL UCLA Wilshire Center, Suite 1700 MC Phone Fax
OCCUPATIONAL HEALTH FACILITY (OHF)
Center for Health Sciences
Monday through Friday
7:00 a.m. to 4:30 p.m.
Mail Code
Phone
Fax
EMERGENCY DEPARTMENT
757 Westwood Plaza
(ER entrance Gayley Ave, north of Le Conte)
Phone
Open 24 hours a day
SMH Emergency Room
Phone

20. Other Information Health System Policy HS 7318
EMPLOYEE WORK-RELATED ILLNESS AND/OR INJURY
Required WorkPlace posting DWC 7
Notice to Employees – Injuries Caused By Work
HR Website
New Employee Pamphlet
Distributed at time of Hire by HR Rep
Pre-designation of Physician form

21. Health and Welfare, Other benefits Sick leave and vacation accruals Retirement Accruals
WC Options

22. OPTION 1
If FMLA eligible, the employee will be on a FMLA Leave Without Pay
If not eligible for FMLA, the employee will be on Workers’ Comp Leave Without Pay
Employee is fully responsible for insurance contributions according to the FMLA guidelines.
Employee must make employee contribution for health.
Benefits Office will notify the employee directly regarding all benefits which are not paid for by FMLA.
Employee will also need to pay directly for health, dental, and vision once the 12 weeks of FMLA exhaust.
Employee is eligible to accrue full sick leave and vacation while on Option 1 but accruals are awarded only upon Return to Work.
Employee does not earn service credit while on Option 1.
Upon return to work, should contact Benefits Office to initiate service-credit buy-back if applicable

23. OPTION 2 If FMLA eligible, the employee will be on FMLA Leave With Pay
If not eligible for FMLA, the employee will be on Workers’ Comp Leave With Pay
Employee’s regular contributions for insurances, parking, 403(b), and other voluntary deductions are taken from supplemental pay.
Employee’s own contribution for health and other insurances is deducted following normal payroll process.
All contributions remain the same unless employee elects to make a change, e.g. cancels Parking, decreases 403(b) contributions on-line (Fidelity website), cancels or changes insurances or covered members.
Employee is eligible to accrue full sick leave and vacation while on Option 2 AND sick leave accruals are used as accrued
Once the employee’s own sick leave exhausts, the employee is eligible to receive 80% Extended Sick Leave benefit.
Employee earns service credit at 100% of % appointment while on Option 2.

24. OPTION 3 If FMLA eligible, the employee will be on FMLA Leave With Pay
If not eligible for FMLA, the employee will be on Workers’ Comp Leave With Pay
Employee’s regular contributions for insurances, parking, 403(b), and other voluntary deductions are taken from supplemental pay.
Employee’s own contribution for health and other insurances is deducted following normal payroll process.
All contributions remain the same unless employee elects to make a change, e.g. cancels Parking, decreases 403(b) contributions on-line (Fidelity website), cancels or changes insurances or covered members.
Employee is eligible to accrue full sick leave and vacation while on Option 3 AND sick leave and vacation accruals are used as accrued
Once the employee’s own sick leave and vacation exhausts, the employee is eligible to receive 80% Extended Sick Leave benefit.
Employee earns service credit at 100% of % appointment while on Option 3.

25. 80% Extended Sick Leave
If FMLA eligible, the employee will be on a FMLA Leave With Pay
If not eligible for FMLA, the employee will be on Workers’ Comp Leave With Pay
Employee’s regular contributions for insurances, parking, 403(b), and other voluntary deductions are taken from supplemental pay.
Employee’s own contribution for health and other insurances is deducted following normal payroll process.
All contributions remain the same unless employee elects to make a change, e.g. cancels Parking, decreases 403(b) contributions on-line (Fidelity website), cancels or changes insurances or covered members.
Employee is eligible to accrue full sick leave and vacation while on 80%Extended Sick Leave but accruals are awarded only upon Return to Work
Employee earns service credit at 80% of % appointment while on 80% Extended Sick Leave.
Upon return to work, should contact Benefits Office to initiate service-credit buy-back if applicable

26. After 80% Extended Sick Leave
Employee will be on a WC Leave Without Pay until Return to Work with or without given Permanent Restrictions
Employee may apply to Liberty Mutual for the Employee-Paid Supplemental Disability to supplement the WC checks.
Health Insurance coverage may continue --
UC Regents will continue to pay the employee’s full health benefits (Employee and University contribution) via the Health Contingency Fund while the employee continues to receive temporary disability payments AND has not been separated.
Employee is eligible to accrue full sick leave and vacation while on receiving WC TTD checks but accruals are awarded only upon Return to Work
Employee must make payment for all other insurances and Benefits that he/she wishes to keep current
Benefits will coordinate direct payment of premiums for all other benefits with employee.