WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE Office of Human Resources. Stay at Work Program

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1 WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE Office of Human Resources Stay at Work Program Revised December, 2013

2 Disclaimer This document should serve as a guideline and should not be construed to supersede any law, rule, or policy. In the case of any inconsistencies, the statutory and regulatory provisions shall prevail. This document is also not designed as a substitute for reasonable accommodation under any applicable federal or state laws, including the Americans with Disabilities Act and the Rehabilitation Act of 1973, including other applicable laws. To preserve the ability to meet needs under changing conditions, the West Virginia School of Osteopathic Medicine reserves the right to revoke, change, or supplement guidelines at any time with written notice. This return-to-work program is not intended to be contractual commitments and they shall not be construed as such by the employees. This program is not intended as a guarantee of continuity of benefits or rights. No permanent employment for any term is intended or can be implied by this program Stay at Work Program (Dec. 2013)

3 Contact Information You must report any work related incident (whether you seek medical treatment or not) with the Office of Human Resources within 24 hours of the incident. Leslie Bicksler, Associate Vice President for Human Resources (800) , ext. 279 (304) Tiffany Burns, Human Resources Representative Senior (800) , ext. 349 (304) Elayne Brown, Human Resources Assistant III (800) , ext. 264 (304) Stay at Work Program (Dec. 2013)

4 Program Information The West Virginia School of Osteopathic Medicine (WVSOM) is implementing a Stay-at-Work program. The purpose and desire of this program is to allow staff the ability to return to WVSOM at the earliest possible time following an injury or illness, whether work-related or not, and to make the transition as smooth as possible while reducing insurance costs. This program applies to all employees of WVSOM and will be followed whenever appropriate. It is the sincere goal of WVSOM to make sure that employees do not return to work before he or she is ready and able to do so and to provide a smooth and positive transition for the employee and employer. The Associate Vice President of Human Resources shall be the designated coordinator of this program. He or she shall contact the injured worker on a regular basis, weekly if possible, and track the employee s recovery and work restrictions. It is the responsibility of the injured worker to provide documentation following each medical visit regarding the injury. When feasible, WVSOM will provide transitional positions to the injured employee in order to minimize or eliminate loss of time, transitional being temporary modified work assignments given the employees physical capabilities, knowledge, and skills. An employee may work within this transitional position as long as the position is available to the employee or until the employee is released back to full-duty with no restrictions. The physical limitations of transitional/ temporary work will be provided by the attending physician. The transitional position is then developed with consideration of the worker s physical abilities, the business needs of WVSOM, and the availability of transitional work. For any business reason, at any time, WVSOM may elect to change the working shift of any employee based on the business needs of this company. WVSOM will determine appropriate work hours, shifts, duration, and locations of all work assignments. WVSOM reserves the right to determine the availability, appropriateness, and continuation of all transitional assignments and job offers. While working under modified duty, or in the transitional position, the employee shall be paid at their base hourly rate. Employee Responsibility Accident Reporting All work related accidents, incidents and injuries must be reported to the Office of Human Resources immediately, regardless if the incident resulted in medical treatment or not. An accident shall be defined as an unexpected and unplanned incident, arising out of or in connection with work which may result in one or more workers incurring a personal injury, disease or death. This would also include traffic accidents should the employee be conducting business on behalf of WVSOM Stay at Work Program (Dec. 2013)

5 Employees are required to complete and submit an Incident Report Form and Bloodborne Pathogen Form (when applicable) within 24 hours of the incident, regardless if the incident resulted in medical treatment or not (form available in the Office of Human Resources or on the website). If the incident does not result in professional medical treatment, the employee must complete the Incident Report Form, submit it to the Office of Human Resources, and also notify his or her supervisor of the incident. If the accident results in professional medical treatment to the employee, the employee must complete the Incident Report Form when able to, and he or she must also tell the individuals providing medical treatment that it is worker s compensation. The employee must also contact the Office of Human Resources as soon as possible. Employee s Physical Condition In the case that the employee has sought professional medical treatment, the employee should indicate to the attending physician that WVSOM has a Stay-at-Work Program in which light duty and/or modified assignments are available to the employee. The employee should obtain an Authorization for Release of Information Form and a WVSOM Job Factor Evaluation and Physician s Statement of Physical Capabilities Form to be completed by his or her supervisor as well as his or her physician (forms available in the Office of Human Resources or on the HR website). Employee is able to return to work If the employee s attending physician releases the employee to return to work, as evidenced by the completion of the Authorization for Release of Information and the completed WVSOM Job Factor Evaluation and Physician s Statement of Physical Capabilities Form, the form shall be returned to the Office of Human Resources prior to the employee s return so that assignments of light duty/ modified work may be appointed or arranged. The employee may not return to work without a release from the attending physician. If the employee returns to a transitional/temporary job, the employee should not exceed the assigned duties of the transitional/temporary job or the physician s restrictions. If the employee s restrictions change at any time, the employee must notify the supervisor immediately and provide the supervisor and the Office of Human Resources a copy of the new medical release. Employee is unable to return to work If the employee is unable to report for any kind of work, the employee shall call in on a regular basis, usually weekly, to report medical status. The employee should make sure that the supervisor and the Office of Human Resources has a current phone number and mailing address where the employee may be reached. The employee shall notify the Office of Human Resources within 24 hours of any changes in their medical condition Stay at Work Program (Dec. 2013)

6 Employer s Responsibilities Accident Reporting The supervisor, Safety Coordinator, and/or Human Resources Representative shall conduct an assessment of the incident regardless of whether the incident resulted in medical treatment or injury. When an accident/incident occurs, and it results in professional medical treatment, it is the Office of Human Resources responsibility to complete the worker s compensation form and submit it to the insurance company (currently Brickstreet Insurance) within 24 hours of when the Office of Human Resources was made aware of the incident. The Office of Human Resources will coordinate with the employee to receive/complete the following information: o Name of the employee s attending physician o Office of Human Resources with the employee s supervisor will complete the WVSOM Job Factor Evaluation and Physician s Statement of Physical Capabilities Form for the employee to take to the attending physician. o Authorization for Release of Information form by employee. o WVSOM Job Factor Evaluation and Physician s Statement of Physical Capabilities Form by employee s physician once completed by the supervisor. The Office of Human Resources will notify the insurance company (Brickstreet currently) of any changes in the worker s medical or work status as soon as possible. Medical Treatment and Temporary/Transitional Duty The Office of Human Resources shall provide to the employee the Authorization for Release of Information to be completed by the employee and the WVSOM Job Factor Evaluation and Physician s Statement of Physical Capabilities Form by employee s supervisor and attending physician. Once this form is completed, the Office of Human Resources shall provide the information to the insurance company and place in the employee s file. The Director of Human Resources and the employee s supervisor will develop a transitional/temporary job assignment for the employee upon their return to work. Supervisor s Responsibilities The supervisor, along with the Office of Human Resources, will develop a transitional/ temporary job assignment given the employee s current capabilities and job function. The supervisor will monitor the employee s performance to ensure that he or she does not exceed the physician s release. The supervisor will monitor the employee s recovery progress through regular contact to assess when and how often duties may be changed. The supervisor will assess WVSOM s ability to adjust work assignments upon receipt of changes in physical capacities Stay at Work Program (Dec. 2013)

7 West Virginia School of Osteopathic Medicine 400 North Lee Street Lewisburg, West Virginia Phone: (304) / Fax: (304) Incident Report This form must be submitted to the Office of Human Resources within 24 hours of the incident. Name:,, / / Last Name First Name MI Report Date Dept: Job Title: / / Date of Hire INCIDENT DATE: / / INCIDENT TIME: A.M. /P.M. Room: Building: Area: Incident type: Injury Type: Body Part injured: Injury Caused By: Equipment/Manufacturer: Model #: Chemical/Cleaning Agent/Hazardous Material/Infectious Material* Involved: What, if any, Personal Protective Clothing/Equipment was used? Did the Personal Protective Clothing/Equipment fail? Please describe: Describe Property Damage (when applicable): INJURY REPORTED TO: Date: / / Time: A.M/P.M. Task being performed at the time of incident: Employee s supervisor complete the following: Ambulance Requested: [ ] Yes [ ] No First Aid Provided (excluding ambulance personnel): By Whom: Transported to: Incident Cause: [ ] Unsafe Act [ ] Unsafe Condition [ ] Unsafe Equip [ ] No Training [ ] Poor Housekeeping [ ] Material Handling [ ] Other Incident Investigated by: [ ] HR [ ] Safety Coordinator [ ] Supervisor [ ] Other Date of Investigation: / / Name of Investigator(s): Time of Investigation: A.M. /P.M. Witnesses: Does Incident Warrant Further Investigation? [ ] Yes [ ] No By Whom? [ ] Dept. Head [ ] HR [ ] Safety Coordinator [ ] Supervisor Describe how and where the incident occurred and what actions, events, or conditions contributed to the incident. Supervisor recommendation(s) for corrective action: Please submit to the Office of Human Resources / / / / Employee s Signature Date Supervisor s Signature Date Date report received by the Office of Human Resources: / / Date information sent to Worker s Compensation: / / Follow-up with injured person: Telephone call Letter Personal Visit Signature of Human Resources Representative/Title *If the incident involved Infectious Material, the employee will be required to complete the Bloodborne Pathogen Form to accompany this form.

8 West Virginia School of Osteopathic Medicine Lewisburg, West Virginia Phone: (304) / Fax: (304) Bloodborne Pathogen Exposure Incident Report Form This form must be submitted to the Office of Human Resources within 24 hours of the incident and this form should accompany the WVSOM Incident Report Form. Name:,, / / Last Name First Name MI Report Date Dept: Job Title: / / Date of Hire Exposure Incident: Date of Exposure: / / Potentially Infectious Materials Involved (blood, body fluids, cell line, etc.): Source (from individual, supplier, exposure to waste, etc.): If source is from individual, please provide the health status of the individual, if known Describe the task being performed at time of exposure: Identify the route of exposure (skin, eye, mucous membrane, etc.): Has the employee received the Hepatitis B Vaccine: [ ] Yes [ ] No If Yes, Please provide vaccination dates: Dose #1: / / Dose #2: / / Dose #3: / / Please submit to the WVSOM Office of Human Resources / / / / Employee s Signature Date Supervisor s Signature Date Date report received by the Office of Human Resources: / / Date information sent to Worker s Compensation: / / Signature of Human Resources Representative/Title

Authorization for Release of Information I,, hereby authorize, to furnish written information to the West Virginia School of Osteopathic Medicine, my employer, regarding my residual functional

9 Authorization for Release of Information I,, hereby authorize, to furnish written information to the West Virginia School of Osteopathic Medicine, my employer, regarding my residual functional capacity, any limitations or restrictions on my ability to perform the functions of my position and any devices, equipment, or accommodations I require to enable me to perform these functions. I understand that I may revoke this authorization at any time by sending a written statement to West Virginia School of Osteopathic Medicine, 400 North Lee Street, Lewisburg, WV The statement must identify this authorization by referring to the date it was signed (below). The statement must include the date on which this authorization is no longer in force. I understand that if I revoke this authorization, my employer may still use and disclose information for which an action has already been taken in reliance on this authorization. Printed Name Signature Date (The original form must be signed and retained by the employer with a photocopy forwarded to the physician.) Please return the form to: West Virginia School of Osteopathic Medicine Office of Human Resources 400 North Lee Street Lewisburg, WV (800) (304) Fax lbicksler@osteo.wvsom.edu

10 Job Function Evaluation SECTION I: GENERAL INFORMATION Employee Name: Company: Job Title: Check one: Current Job Current Job Job Function (provide basic description of the job duties): West Virginia School of Osteopathic Medicine SECTION II: WORK LOCATION Indoors Outdoors Below Ground Elevated Areas Heated Not Heated Temp. Extremes No Temp. Extremes Personal Protective Equipment Required? SECTION III: WORK POSTURES Work Postures (Work is performed in which postures? Please indicate frequency.) Standing Sitting Walking Climbing Kneeling Pushing Pulling (6 8 hours a day) (2 6 hours a day) (0 2 hours a day) SECTION IV: PHYSICAL DEMAND Lifting: Describe Materials: Weight of Materials: How ly: Carrying: Describe Materials: Weight of Materials: Distance Carried: Describe List of Tools Used: Work Hours: Number/Length of Breaks: Please Indicate any Other Special or Unusual Job Demand(s): Completed By: Title: Date: Physician Release to perform these duties? Date of Release: Physician Signature: Please return completed form to: WVSOM-HR, 400 North Lee Street, Lewisburg, WV 24901

11 Physician Statement Of Physical Capabilities Employee Name Please complete this form after your examination of the patient. Indicate the patient s restrictions, if any, including modified hours, duties, environmental factors and any other information pertinent to this employee s healthy recovery and possible early return to work. Medical Diagnosis: In an eight-hour workday, how many hours can this employee: Sit ly With Rests Stand ly With Rests Walk ly With Rests In a given day, how many total hours can this employee work? Upper Extremities Which hand is dominant? Can the employee perform these repetitive actions? Simple grasping Pushing and pulling Left L Yes R Right No Lower Extremities Can the employee perform repetitive actions to operate foot controls or motor vehicles? Yes L R L R Please indicate the extent to which the employee can perform the following: (N = Never, O = Occasionally, F = ly, C = ly) Lifting / Carrying N O F C Activity 10 lbs. or less Bend lbs. Squat lbs. Kneel lbs. Twist / Turn lbs. Climb Pushing / Pulling Crawl lbs. Reach Above Shoulder lbs. Type / Keyboard lbs. Driving lbs. Automatic 100+ lbs. Standard Comments: L R No Simultaneous Left Left Yes Right Right No N O F C Physician Name: Physician Telephone: Date released with above restrictions: Physician Signature: Date released for full-duty work: Date: Please return completed form to: WVSOM-HR, 400 North Lee Street, Lewisburg, WV 24901

This policy applies to all locations or projects where a Return-to-Work Program may need to be implemented.

Scope and Application This policy applies to all locations or projects where a Return-to-Work Program may need to be implemented. It is our goal to return employees, who have sustained a compensable injury,