Office of Human Resources

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1 Dodge City School District #443 Accident, Injury, Illness and Near-Miss Reporting Procedures The accident reporting procedures outlined for Dodge City School District #443 is designed to have the necessary reports filed in the required time frame. This process ensures that the critical information is documented which assists in finding and correcting the underlying causes to prevent recurrence. Procedures: Immediately upon recognizing or an employee reports an injury or illness, assess the seriousness of the employee s condition. Provide first aid, call for additional assistance, and if the injury warrants, call 911. In all cases protect the employee from additional injury. It is the responsibility of the employee to report any injury while on the job immediately to their supervisor, and to the Human Resources Benefit Specialist. In situations where the injury or illness is not determined to be a medical emergency, but where medical treatment is deemed necessary, the immediate supervisor must assist the employee in seeking medical treatment from the medical provider listed below for all work related injuries or illnesses. Ms. Stacey Zubia Scheduling Coordinator direct line If no answer, call Dodge City Medical Center 2020 Central Avenue Dodge City, Kansas When calling DCMC, confirm with the Scheduling Coordinator USD 443 employment, employee s full name, and employee s date of birth. This will expedite treatment for the employee. After 5:00 p.m. on a work day and/or weekend, the employee should see the Physician On-Call at Western Plains Regional Medical Center Emergency Room Dodge City, Kansas. The Supervisor Report of Accident, the Employee Report of Accident and if applicable the Witness Report are required to be filled out to document the accident/injury within 24 hours. These reports need to be sent to the Human Resources Benefits Specialist. The immediate supervisor will provide the employee the Medical Activity Authorization Form. The injured employee must take this form to the medical provider at the time of the first visit, if not an emergency. Before leaving the office of the medical provider, the employee must have the medical provider complete and sign the Medical Activity Authorization Form. The Medical Activity Authorization Form must be returned to the Human Resources Benefit Specialist the same day. If the accident/injury

2 occurs at the end of a work day, the Medical Activity Authorization Form is to be returned the beginning of the next work day. No employee will be allowed to return to work without a completed Medical Activity Authorization Form. The immediate supervisor, in consultation with the Human Resources Office, will determine if duty restrictions/modifications specified on the Medical Activity Authorization Form can be accommodated per the employee s job description. Each follow-up visit to the doctor will require an updated Medical Activity Authorization Form, signed by the doctor. Once an employee has been returned to his/her regular duties but has ongoing medical treatment, the employee will continue to provide an updated Medical Activity Authorization Form after each appointment. The updated reports are to be returned to the Human Resources Benefit Specialist. The Executive Director of Human Resources shall review accident/injury reports and determine which require further investigation, follow-up, and/or recommended corrective action. Failure to follow these procedures will result in, but not limited to, disqualification of workers compensation benefits and/or disciplinary action. For questions or further information, please contact: Marcia Gutierrez, Benefits Specialist USD 443 Human Resources Office Administration Building, 1000 North 2 nd Ave Room USD 443 HR: 11/11/15

3 USD 443 Employee Accident Report Form Note: To preserve your rights under the law, you must give or cause to be given a written notice of the accident to the School District, in this case, 24 hours from the incident. This notice is to be given immediately upon occurrence of the accident. I hereby provide notice that I,, was injured or contacted an occupational disease on / / at (am) (pm). (Date of accident) (Please Print Name) (Time of accident) Actual location of the accident:. Name of the school and /or Facility:. Nature of your injury:. The part of body injured:. What happened? Describe how the injury occurred. Examples: When the ladder slipped on the wet floor, I fell 20 feet. OR I was sprayed with chlorine when a gasket broke during replacement. Describe what you were you doing just before the incident occurred. Describe the activity, as well as the tools, equipment or materials that you were using. Be specific. Examples: "I was climbing a ladder while carrying tools A, B, C, and D"; "I was spraying chlorine from hand sprayer." Describe the illness/injury. Indicate the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn on my hand.

4 List the object or substance that directly harmed you. Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank. Were Safeguards/Safety Equipment Provided? If yes, were they used? How could the injury/illness have been prevented? Employment Status: Full Time Part Time Temporary Occupation (job title) when injured: Time you began work on day of injury: a.m. p.m. Date of Birth: / / Sex: Male Female PENALTY FOR FRAUD NOTE: WORKER S COMPENSATION AST, ARTICLE 1, SECTION : (a) Any person who willfully makes a false statement or representation of a material fact for the purpose of obtaining or denying any benefit or payment, or assisting another to obtain or deny any benefit or payment under this Article, shall be guilty of a Class 1 misdemeanor if the amount at issue is less than one thousand dollars ($1,000). Violation of this section is a Class H felony if the amount at issue is one thousand dollars ($1,000) or more. The court may order restitution. BY MY SIGNATURE, I CERTIFY THAT ALL THE ABOVE STATEMENTS ARE TRUE AND ACCURATE, AND THAT I HAVE READ AND UNDERSTAND THE ABOVE ARTICLE. (Signature of Accident Witness) / / Telephone Date / / (Signature of Injured Employee) Telephone Date USD 443 HR:

5 Accident Report of Eyewitness USD 443 Name of Injured Employee: Date of Incident: Name of Witness: Address: Telephone Number: In your own words, please describe what happened, as you witnessed it: Did anyone else see the accident? Yes No If yes, please list their names: Other Comments: Signature of Eyewitness Date

6 ACCIDENT INVESTIGATION REPORT (Completed by Supervisor of Injured Employee) District Incident Location (school) Injured Employee Consecutive Hours Worked Position How long in position? Date of Accident / / Time of Accident a.m. p.m. Nature of Injury Has employee been trained? Yes No If so, When? Medical Treatment None First Aid EMT/Paramedic Doctor/Clinic Hospital Days Lost Time? What was the injured employee doing immediately prior to, and at the time of the accident? How did the accident occur (brief description)? What unsafe conditions contributed to the accident? What unsafe acts contributed to the accident? What corrective actions can be taken to prevent recurrence? What corrective actions have been taken to prevent recurrence? Was this accident reviewed by the Safety Committee? Yes No Safety Committee Recommendation: Supervisor: Reviewed by: Date: Date:

7 ATTENTION DODGE CITY MEDICAL CENTER STAFF: Once USD 443 employees is diagnosed, and determination is made for referral to a specialist, additional procedures (i.e., MRI, CAT scan, etc.), etc., immediately contact for referral authorization and further direction of medical treatment: United Heartland P.O. Box 3026 Milwaukee, WI Claims Contact Information: Alan Worden, Ph: , Fax: Bill Payment Inquiries/Questions: USD 443 MEDICAL ACTIVITY AUTHORIZATION FORM Employee Name (Please print) Job Title Location Essential Job Functions (List): Employee works hours/day, through between the hours of am/pm and am/pm. Employee s job duties are performed in: an office; a warehouse; the outdoors; a classroom another environment (describe): If work is in multiple locations, estimate percentage of time in each. PHYSICIAN S ASSESSMENT To Be Completed By The Physician WORK STATUS: Regular Work No Work Modified Work; Restrictions Listed Below WORK RESTRICTIONS (If Applicable): Minimal limited use of No use of arm overhead Lifting up to pounds No use of hand Pushing/pulling up to pounds No repetitive No repetitive bending No operation of mobile equipment or machinery No squatting or kneeling No work above floor level, on/near dangerous equipment No climbing No exposure to dust, fumes, or smoke No prolonged walking or standing. Should be sitting % of the time Other (please describe): The employee may perform the following job functions and tasks under the conditions specified below: Estimated Length of Time Off: Estimated Date to Return to Regular Work: Estimated Date to Begin Modified Work, if Available: This employee is scheduled for a follow-up evaluation on: Date / / Physician Signature Physician Address Physician Phone # PLEASE RETURN THIS COMPLETED FORM TO THE USD 443 HUMAN RESOURCES OFFICE Contact Information Listed At The Top Of This Form

8 USD 443 Dodge City Public Schools Worker s Compensation Notice USD 443 is subject to the Kansas Worker s Compensation Law, which provides compensation for work-related injuries. What do you do if an accident occurs on the job? Notify your supervisor immediately. A written report must be filed by the injured employee immediately after the accident or the next business day. Injuries during the regular work day (8:00am-5:00pm) should be seen at: Dodge City Medical Center 2020 Central Avenue Contact: Ms. Stacey Zubia Scheduling Coordinator direct line If no answer, call After 5:00pm on a work day and/or weekend, the employee should see the Physician On-Call at Western Plains Regional Medical Center Emergency Room Dodge City, Kansas. The hospital should notify: Marcia Gutierrez, USD 443 Benefits Specialist Human Resources Office 1000 North 2 nd Ave. Room The employee should contact his/her immediate supervisor the next business day re: any additional medical care. Medical Benefits: An employer is required to furnish all necessary medical treatment and has the right to designate the treating facility. The designated treating facility for USD 443 is: Dodge City Medical Center 2020 Central Avenue Contact: Ms. Stacey Zubia Scheduling Coordinator direct line If no answer, call If the employee seeks treatment from a medical facility not authorized by the employer, the employer or its insurance carrier is only liable up to $

9 Weekly Benefits: Benefits are paid by the employer s insurance carrier. Injured workers are not entitled to compensation for the first week they are off work unless they lose three consecutive weeks. The first compensation payment is normally due at the end of the 14 th day of lost time. An injured employee is entitled to weekly amount of 66 2/3% of his average week wage up to a maximum of 75% of the state s average weekly wage. These benefits are subject to legislative changes. If the injury results in permanent disability, the Kansas compensation law provides. District policy permits an employee to receive combined worker s compensation benefits and salary allowed under sick leave, or other pay. The salary portion shall be prorated according to the percent of daily wage that would come from accumulated sick or other available leave until such leave is exhausted. When all appropriate leave is used, the employee will receive the applicable worker s compensation benefit until the end of the benefit period. Where to get help or information on your claim: Contact the Claims Advisory Section at the Kansas Division of Worker s Compensation (DWC) immediately if you do not receive compensation in a timely manner. The DWC has full-time personnel who specialize in aiding injured workers with claim questions. DWC can be reached at: Division of Workers Compensation 800 SW Jackson Street, Suite 600 Topeka, KS Currently, USD 443 claims are administered by: United Heartland ATTN: Work Comp Department P.O. Box 3026 Milwaukee, WI Claims Contact Info: Alan Worden, Ph: , Fax: Bill Payment Inquiries/Questions: Ph: For further information, contact: Marcia Gutierrez, Benefits Specialist USD 443 Human Resources Office Administration Building, 1000 North 2 nd Ave Room USD 443 HR: