1. Chief Executive Office Risk Management RETURN TO WORK Unit
RETURN TO WORK 101 INJURY REPORTING
Chief Executive Office Risk Management RETURN TO WORK Unit

2. Topics Covered WC Overview Forms/Process Work Hardening (WHTAA)
Completing Forms
Seeking medical treatment via Pre-designation or Initial Treatment Center (ITC)
Work Hardening (WHTAA)
Maintaining File/Contact with Employee

3. Workers’ compensation overview
Injury definition: Any injury or disease arising in the course and scope of employment
Applicable labor code section;
“…shall be liberally construed by the courts with the purpose of extending their benefit for the protection of persons injured in the course of their employment.” (LC3202)

4. Workers’ compensation overview, cont…
Third Party Administrator
Contractor hired by County of Los Angeles to administer workers’ compensation benefits for County employees
Decides whether workers’ compensation claims are compensable (work-related)
Decision must be made within 90 days of receiving claim form

5. Breakdown of injury reporting PROCESS
Emergency Injury Reporting
Non-Emergency Injury Reporting
Employee Seeks Treatment
Employee Injury/Illness File
Employee on Temporary Total Disability
Employee Released to Full Duties
Employee Release to Modified or Alternative Work
Required Forms

6. Emergency injury reported
CALL 911

7. Emergency injury reported, cont…
Once the situation is stable, you should:
Complete the DWC1 Claim Form, and the Employer’s Report of Injury (5020) and call into the Toll-Free number within 24 hours.
Complete the Job Description form.

8. WORKERS’ COMPENSATION CLAIM FORM (DWC 1)

9. EMPLOYER’S REPORT OF OCCUPATIONAL INJURY/ILLNESS (5020 FORM)

10. JOB DESCRIPTION FORM

11. JOB DESCRIPTION FORM

12. FIRST ALERT FORM

13. NON-EMERGENCY INJURY REPORTED
If Employee Declines Treatment:
Employee must complete the Employee’s Statement Declining Treatment form. A copy of the form must be sent to the RTW Coordinator or Personnel.
Employee must sign Receipt of Employee Packet, and be given the packet.

14. Employee’s declining medical treatment FORM

15. Receipt of employee packet

16. Employee seeks treatment
Review the Employee’s Guide for Injury Reporting with the employee.
Complete the Injury Reporting forms with the employee. The packet must contain the four forms below:
The completed Treatment Referral Slip
The completed Treating Physician’s letter (for physical injuries only)
A copy of the blank Patient Status Report
A copy of the completed Job Description should be included in the Medical Provider Packet.
Send the four documents with the employee to the
Pre-designated physician OR ITC, as applicable.

17. Treatment referral slip FORM

18. Treating physician’s letter (Physical injuries only)

19. Patient status report FORM (Physical injuries only)

20. EMPLOYEE’S REPORT OF ACCIDENT FORM

21. EMPLOYEE SEEKS TREATMENT CONT…
Ask the employee if they have Pre-designated a treating physician.
If they have not, send them to the Medical Provider Network (MPN) Initial Treatment Center (ITC).
A list of those centers can be obtained on the County’s MPN website at:

22. PREDESIGNATION OF PERSONAL PHYSICIAN FORM

23. EMPLOYEE SEEKS TREATMENT CONT…
Fill out the DWC1 Claim Form, and Employer’s Report (5020) form. The injury must be called into the Toll-Free number within 24 hours upon notice of the injury.
Call the Toll-Free number and report the injury.
In some departments, the main RTW Unit staff calls in the injury, in others the supervisor or location designee calls it in.

24. mpn initial treatment centers (itc)
If Employee has not Pre-designated their personal treating physician, the work location Supervisor or designee must direct them into the County’s Medical Provider Network (MPNs), via an Initial Treatment Center (ITC).

25. Employee on temporary total disability (EMPLOYEE IS TAKEN OFF WORK BY PHYSICIAN AFTER INJURY)
Location Supervisor should fax a copy of the Patient Status Report to the RTW Unit/Personnel.
Make sure that the time card is coded appropriately.
Call the employee for status. The employee should be called on a weekly basis to determine their status, follow-up on their recovery, and answer any questions they may have regarding the process.

26. Employee release to full duties
Return the employee to work.
Communicate with the employee to make sure they are able to continue working their Usual and Customary (U&C) duties.
The department RTW Unit should be informed of status in writing, and of any problems or concerns.
Close the employee injury/illness file in 45 days from the date of injury if the employee continues to work their U&C job.

27. Employee release to modified or alternative work
If a Physician has provided restrictions that prevent employee from immediately returning to their Usual and Customary (U&C) job, proceed with the following:
Review the work restrictions to make sure they are compatible with the duties listed in the job description.
If the work restrictions are compatible, return the employee to work.

28. Employee release to modified or alternative work cont…
If the modification of the job duties is required, make the necessary modifications.
Communicate those temporary modifications and time limits to the employee.

29. Employee release to modified or alternative work cont… (using whtaa form)
If modification of the job is done, a Work Hardening Transitional Assignment Agreement (WHTAA) must be completed with the employee. (This should be done during the Interactive meeting and by either or both the RTW Unit staff or the location Supervisor or designee along with the employee.)
Location Supervisor/designated staff and department RTW Unit staff should both have a signed copy of the WHTAA, along with the employee.

30. Employee release to modified or alternative work (WHTAA) cont…
Retain a copy of the WHTAA in the employee’s injury/illness file.
If modification of the job is not possible, explore available job tasks within the work unit.
If the location is able to provide alternative work, a WHTAA must be completed with the employee.

31. Work hardening transitional assignment agreement (whtaa) form

32. Work hardening transitional assignment agreement (whtaa) form

33. Employee release to modified or alternative work cont…
If no alternative or modified job is available after a thorough and reasonable search is conducted, contact the Supervisor/Management at work location and human resources staff to assist with a plan to monitor situation and expand search for other job placement opportunities within the department.
Catalog a follow-up date with department staff.

34. Employee release to modified or alternative work cont…
When an assignment is located, complete the WHTAA form with the employee on their first day back to work.
Make sure a signed WHTAA form is obtained and maintained between the department RTW Unit and the work location/supervisor/RTW Coordinator.

35. Employee release to modified or alternative work cont…
If there is a problem reaching the employee at home, document attempts on the Telephone Log and work with other County TPA staff as appropriate to verify contact information. If necessary you can contact the treating physician to request medical certification reflecting any restrictions or to verify employee is taken off work.

36. Employee release to modified or alternative work cont…
If you suspect any behavior or receive any information regarding fraudulent activities or abuse, this information should be shared with our TPA staff once their file is set up.

37. Weekly telephone call verification sheet

38. Review of required forms for reporting an industrial injury
Receipt of Employee Packet
Employee’s Statement Declining Medical Treatment
First Alert or other proof of Fax as appropriate
DWC1 Claim Form
Employer’s Report (5020) Form
Job Description Form
Treating Physician’s Letter
Treatment Referral Slip
Work Hardening Transitional Assignment Agreement
Weekly Call Verification Sheet
To locate more forms see:

39. Review of employee responsibilities
Complete DWC-1 Employee Claim Form
Complete Employee’s Report of Accident
Return the Completed forms to your supervisor/including all Medical Certifications from your treating physician

40. Employee injury/illness file
It is important that an injury/illness file be
maintained on employees. The injury/illness
file should contain, at a minimum, the following
documents:
A copy of the Claim Form (DWC Form 1)
A copy of the Employer’s Report (5020)
Copy of the Job Description/Essential Job Functions listing
Employee’s Report of Accident
Patient Status Reports
Work Hardening Agreements
Supervisor Weekly Telephone Log Sheet
Any other documentation that you may receive on this injury

41. Questions???