1. Worker’s Compensation Workshop Procedure for Processing a Worker’s Compensation Claim The Office of Human Resources

2. The Mission of the State Government Worker’s Compensation Program is to ensure ethical and equitable treatment of injured employees in a cost efficient manner.

3. What Constitutes a Worker’s Comp. Claim? An On-the-job injury due an incident occurring on or off campus.

4. Who is Covered? Permanent Employees Temporary Employees Part-Time Employees Working Students Who is Not Covered? Independent Contractors Non-Working Students

5. Supervisor’s Responsibilities Ensure that the injured employee receives immediate and appropriate medical attention Direct the employee to the authorized primary care physician Complete the required NCIC Form 19 and forward to the Worker’s Compensation Administrator within 24 hours of the injury Assist in the accident investigation to determine the cause of the accident Correct unsafe conditions immediately Communicate with injured employees to ensure their needs are met. If the employee is out of work make contact weekly. Report the total number of days missed due to injury to the WC Administrator

6. Authorized Primary Care Physician Prime Care of Highland Oaks 600 Highland Oaks Drive Winston Salem, NC 27103 (336) 774-0044

7. If it is a life threatening emergency, or after hours go to the nearest medical facility

8. Filing a Claim Contact HR for a Form 19 and Medical Authorization Form Complete a NC Industrial Commission Form 19 (Employee must sign and date form on the back) Send the Form 19 to Benefits Rep. in Human Resources Give the injured employee the Medical Authorization Physician’s Report write “No Drug Test” in the upper right corner Send the employee to the care provider listed on the Quick Reference Guide Employee should return the Medical Authorization form to his/her supervisor or office manager to forward to HR If he/she is given a prescription please send them to one of the pharmacies listed on the reverse side of the Quick Reference Guide for Employees.

9. Forms

10. Medical Authorization Form http://www.keyrisk.com/pdfs/clai msPharmacy-PhysiciansReport.pdf http://www.keyrisk.com/pdfs/clai msPharmacy-PhysiciansReport.pdf If the employee has to be rushed to an emergency facility, this form can be waived for a hospital report form.

11. Prescription Pharmacy Form

12. In case of an extreme emergency and the injured employee is taken to the emergency room; The same forms are needed. A police report must be filed with the form 19 and the Medical Authorization Form or a hospital report form.

13. What Do I Do If an Employee Refuses Treatment? Notify Mary Ellen Haynes in Human Resources Note: An employee can still file a claim within the 2-year period allowed by law, even if a release statement of Refusal of WC Benefit was provided.

14. WC Leave Policy Day of Injury No leave is charged on the day of the injury if the treating physician instructs the employee not to return to work and provides a statement

15. WC Leave Policy Leave Options Elect to take sick or vacation leave during the required waiting period and then go on WC leave and begin drawing WC weekly benefits. Elect to go on WC leave with no pay for the required waiting period and then begin drawing WC weekly benefits.

16. Worker’s Compensation Administrator Mary Ellen Haynes, Benefits Representative 770-1451 haynesm@ncarts.edu