IMMEDIATE. If you question the claim, DO NOT ADVISE THE EMPLOYEE OF THIS. WITHIN 2-3 WORKING DAYS

Size: px
Start display at page:

Download "IMMEDIATE. If you question the claim, DO NOT ADVISE THE EMPLOYEE OF THIS. WITHIN 2-3 WORKING DAYS"

Transcription

1 ON THE JOB INJURIES PROCEDURES AND FORMS A PROUO-' l'rogjiejsiye nllage FOR ALL PEDl'lE IMMEDIATE a) Employee reports injury to immediate supervisor. IF THERE IS A FATALITY, SERIOUS INJURY OR QUESTIONABLE CLAIM, CONTACT HUMAN RESOURCES OR ADMINISTRATION IMMEDIATELY FOR FURTHER INSTRUCTIONS. Supervisor/Manager to let Human Resources know about the injury so they can complete a Physician's Immediate Care Authorization Form and send directly to them. If you question the claim, DO NOT ADVISE THE EMPLOYEE OF THIS. WITHIN 2-3 WORKING DAYS a) Supervisor must complete Illinois Form 45 Employer's First Report of Injury and send to Human Resources. If you have questions on how to complete, contact Human Resources. b) Employee must return to work immediately following treatment at Physician's Immediate Care and submit to the supervisor the Physician's Immediate Care Injury Status Report. c) The supervisor must complete a Medical CES Form with the Physician's Immediate Care Injury Status Report attached, after employee returns from the clinic visit. ADMINISTRATIVE APPROVAL IS REQUIRED ON ALL MEDICAL CES FORMS. d) Employee must complete an Employee Statement of Injury form. e) If you receive any inquiries regarding the verification of worker's compensation benefits, any subpoenas or inquiries from attorneys other than ours immediately refer them to the HR Division. DO NOT RELEASE ANY INFORMATION.

2 ACCIDENT INVESTIGATION a) Within 5 days, select an Accident Review Panel (ARP). b) ARP shall meet within 5 days to review the accident and shall complete Accident Review Panel Findings report and submit to employee's supervisor(s). c) Employee's immediate supervisor(s) shall review the ARP report and complete supervisor section and submit report to department head. d) Department head shall review report and recommendations, and make final determination if disciplinary action should be taken. SEND COPY OF COMPLETED REPORT TO HUMAN RESOURCES. e) If disciplinary action is warranted, department head shall complete Employee Warning Record Form. IMPORTANT POINTS TO REMEMBER a) Employees on Restricted Duty Status are responsible for working within all doctor recommended restrictions to prevent further injury. Supervisors must exercise good judgment in assigning work to prevent further injury. The Village Administrator or designee must approve all restricted/light duty requests. b) Employees on Restricted Duty Status or Total Temporary Disability (TTD) are responsible for scheduling and meeting all follow-up visits with Physicians Immediate Care or other treating physicians, and submitting to their supervisors all Injury Status Reports. Failure to comply may result in denial of Workman's Comp benefits. Any physical therapy or follow-up appointments, etc. should be scheduled as close to the scheduled starting time or ending time of the workday for that employee. c) Department Heads are responsible for submitting all Injury Status Reports and Medical CES Forms to Human Resources. d) Department Heads shall be responsible to periodically contact an employee on TTD to discuss progress of recovery. A status update of such contact shall be made to the Village Administrator or HR Division. e) Medical reports provided by ECS and Minnich & Associates, Inc. are considered confidential and are required to be kept in a separate confidential file in the Human Resources Division. Department heads shall be permitted to review confidential files upon request at the Human Resources Division. Revision Date 04/15

3 IWNOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY Please type or print. Employer's FEIN Date of report Case or File # Is this a lost workday case? Employer's name Village of Glendale Heights Employer's mailing address Doing business as Same Yes I No 300 Civic Center Plaza, Glendale Heights, IL Nature of business or service Municipality SIC code Name of workers' compensation carrier/admin. Policy/Contract# Self-insured? Employer's Claim Service, Inc. (Ye';)/ No Employee's full name Birthdate Employee's mailing address Employee's address # Dependents Employee's average weekly wage Male I Female Married I Sinr le Job title or occupation Date hired Time employee began work AM Date and time of accident PM If the employee died as a result of the accident, give the date of death. Address of accident Last day employee worked Did the accident occur on the employer's premises? Yes I No What was the employee doing when the accident occurred? How did the accident occur? What was the injury or illness? List the part of body affected and explain how it was affected. What object or substance, if any, directly harmed the employee? Name and address of physician/health care professional If treatment was given away from the worksite, list the name and address of the place it was given. Was the employee treated in an emergency room? Was the employee hospitalized overnight as an inpatient? Yes I No Yes I No Report prepared by Signature Title and telephone # Please send this form to the ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD. SPRINGFIELD, IL IC45 11/11 By law, employers must keep accurate records of all work-related injuries and illness (except for certain minor injuries). Employers shall report to the Commission all injuries resulting in the loss of more than three scheduled workdays. Filing this form does not affect liability under the Workers' Compensation Act and is not incriminatory in any sense. This information is confidential.

4 Employee Name OFull-Time Temporary EMPLOYEE'S STATEMENT OF ACCIDENT/ INJURY Position J ~ D Part-Time Oseasonal Osummer D Department. Name of Immediate Supervisor Division How long have you worked in this position and divisio.,_n:..:.?, Years in Position I I Years in Division._I. Date & Time of Accident/ Injury._I / / A_M_/_P_M, Date & Time Reported._I / / A_M_/ P_M,I Explain exactly what you were doing and the circumstances leading to the accident I injury, include the description of the nature of your injury. Were you using Personal Protection Equipment that is required when performing this work? YesO No D Comment: - continued on back -

5 Describe any unsafe act(s) conditions or behavior that contributed to this accident I injury. Explain how you feel this accident I injury could have been prevented: I affirm the above statement is true and complete to the best of my knowledge and belief. Employee's signature: Date:

6 ~ l'xouo ~ IROCiRfttJYE VlltAGE FOR A/.l /Wl'LE VILLAGE OF GLENDALE HEIGHTS ACCIDENT AND INJURY REVIEW PANEL FINDINGS Employee: Date: Vehicle number (if applicable): Accident/ Injury description: Date of occurrence: Define the unsafe act(s) and behavior or conditions contributing to the accident/ injury: Recommendations to avoid future re-occurrence: Other panel findings: PreventableD Non-Preventable D Review panel member's signatures:

7 Supervisor's comments to the Department Director: At Fault: D Not At-Fault: D Disciplinary Action: Yes D D Disciplinary Action: Signature: Date: Director's Findings: Signature: Date:

8 EMPLOYEE WARNING RECORD Employee's Name Payroll No. Dept. Shift Time Date of Warning Date of Violation Time of Violation Place Violation Occurred WARNING Nature D Substandard Work D Conduct D Tardiness of D Carelessness D Disobedience D Other ---- Violation VILLAGE REMARKS Has Employee Form of WHEN WARNED ANDBYWHOM Been Warned Warning I sr Warninl! 2"d Warninl! 3,d Warning Previously Oral Yes No Written EMPLOYEE REMARKS RE: VIOLATION The absence of any statement on the part of the EMPLOYEE indicates his/her agreement with the report as stated. I have entered my version of the matter above. Employees Signature Date ACTION TO BE TAKEN Approved BY-----,-, Name I have read this "warning" and understand it. Title Date Employee's Signature Date Si!!l1ature of oerson who ore""red Wamina Distribution of copies Title Date _Employee _ Personnel Department - Foreman or _ Plant Manager Supervisor Employees Union Rep Suoervisor's SiPnature Date

UPMC POLICY AND PROCEDURE MANUAL

UPMC POLICY AND PROCEDURE MANUAL SUBJECT: Fitness for Duty DATE: November 8, 2013 I. PURPOSE/SCOPE UPMC POLICY AND PROCEDURE MANUAL POLICY: HS-HR0721 * INDEX TITLE: Human Resources This policy applies to all United States based UPMC staff

More information

INJURY AND ILLNESS PREVENTION PROGRAM. Adopted June 25, 1991 by Board Resolution 91-95

INJURY AND ILLNESS PREVENTION PROGRAM. Adopted June 25, 1991 by Board Resolution 91-95 INJURY AND ILLNESS PREVENTION PROGRAM Adopted June 25, 1991 by Board Resolution 91-95 Latest Annual Review/Revision December, 2012 TABLE OF CONTENTS 1.0 Introduction... 1 2.0 Definitions... 1 3.0 Policy...

More information

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

WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE Office of Human Resources. Stay at Work Program WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE Office of Human Resources Stay at Work Program Revised December, 2013 Disclaimer This document should serve as a guideline and should not be construed to supersede

More information

These forms must be completed for absences more than 20 consecutive work days

These forms must be completed for absences more than 20 consecutive work days LEAVE OF ABSENCE PACKET FOR CLASSIFIED EMPLOYEES These forms must be completed for absences more than 20 consecutive work days CONTENTS This leave of absence packet contains the following items: 1. Instructions

More information

non-high hazard employers

non-high hazard employers I,.: ol c.. 1;ro,. 1 "' for non-high hazard employers [GUo5HAi] " -...,... ;:.-;-;... CS- I revised October 200 I Cal/OSHA Consultation Service State of California.Department of Industrial Relations Division

More information

Ames Public Library Policy Section: Personnel Approved: 5/98 Subject: Performance Discipline Reviewed: 4/01 Revised:

Ames Public Library Policy Section: Personnel Approved: 5/98 Subject: Performance Discipline Reviewed: 4/01 Revised: Ames Public Library Policy Board Section: Personnel Approved: 5/98 Subject: Performance Discipline Reviewed: 4/01 Revised: Purpose The purpose of this policy is to ensure the orderly and efficient operation

More information

HEALTH AND SAFETY PROTECTION ON THE JOB

HEALTH AND SAFETY PROTECTION ON THE JOB HEALTH AND SAFETY PROTECTION ON THE JOB Wyoming Department of Workforce Services Notice to Employees Health and Safety Protection on the Job Page 1 of 2 The Wyoming Occupational Health and Safety Act provides

More information

1. DJJ will not grant an employee the use of sick leave before such leave is earned, as provided for in this policy.

1. DJJ will not grant an employee the use of sick leave before such leave is earned, as provided for in this policy. GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: {x} All DJJ Staff {x} Administration {x} Community Services {x} Secure Facilities (RYDC s and YDC s) Chapter 3: PERSONNEL Subject: SICK LEAVE AND SPECIAL

More information

Return to Work Policy and Procedure

Return to Work Policy and Procedure Return to Work Policy and Procedure Category: Number: Responsibility: Approval: Amendments: Human Resources HU1 Director of Human Resources January 2016, Administration Every 5 years or as circumstances

More information

Workers Compensation Return-To-Work Guidelines

Workers Compensation Return-To-Work Guidelines Workers Compensation Return-To-Work Program Guidelines Official Title Workers Compensation Return-To-Work Guidelines Responsible Party Office of Human Resources Revised July 2015 PROGRAM STATEMENT When

More information

Summary HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS. OWCP Form CA-2 Instructions Notice of Occupational Disease and Claim for Compensation

Summary HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS. OWCP Form CA-2 Instructions Notice of Occupational Disease and Claim for Compensation OWCP Form CA-2 Instructions Notice of Occupational Disease and Claim for Compensation Summary Purpose Official notice to the employee s supervisor and to the OWCP of a condition believed by the employee

More information

MEDICAL LEAVE OF ABSENCE REQUEST FORM

MEDICAL LEAVE OF ABSENCE REQUEST FORM MEDICAL LEAVE OF ABSENCE REQUEST FORM Section 1: For completion by the Employee The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support

More information

Recover at Work Program

Recover at Work Program Recover at Work Program General Information Skillset Limited has developed a specific Recover at Work Program, which will form an integral part of the Company s overall Risk Management system. The objectives

More information

Revised July 2015 WORKERS COMPENSATION TIME REPORTING MANUAL

Revised July 2015 WORKERS COMPENSATION TIME REPORTING MANUAL WORKERS COMPENSATION TIME REPORTING MANUAL Table of Contents Purpose of the Manual 1 General Information 1 Time Reporting Guidelines 2 USPS, Faculty, and A&P Employees` 2 Shift Workers 3 OPS Employees

More information

Providing a workplace free from recognized hazards and complying with OSHA standards Maintain conditions and adopt practices reasonably necessary to protect workers on the job Be familiar with the standards

More information

Accident Prevention & Safety Manual

Accident Prevention & Safety Manual Sanchez Commercial & Security Services Accident Prevention & Safety Manual Sanchez Commercial & Security Services 1169 N. Burleson Blvd. Suite #107, Box 262 Burleson, TX 76028 Tele. (817) 905-6893 Origination

More information

NATIONAL COMPETENCY STANDARD

NATIONAL COMPETENCY STANDARD NATIONAL COMPETENCY STANDARD WSQ Framework : WSH Professionals Competency Category : Check and take corrective and preventive actions for WSH Competency Code : WP-CA-301C-1 Competency Unit : Investigate

More information

Health and Safety Policy

Health and Safety Policy Health and Safety Policy Policy statement Brunk is committed to meeting our health and safety goals for all processes, and to maintaining a safe and healthy workplace. It is Brunk s policy to provide a

More information

This directive provides guidelines for the application of the Division's sick leave policy.

This directive provides guidelines for the application of the Division's sick leave policy. Title: Sick Leave Related MD Statute/Regulations: Federal Family & Medical Leave Act Related ACA Standards: N/A Directive Number: DPDS.050.0008 Supersedes: DPDS.050.0025, titled Sick Leave and issued on

More information

APPLICATION FOR EMPLOYMENT City of Henderson, N.C.

APPLICATION FOR EMPLOYMENT City of Henderson, N.C. APPLICATION FOR EMPLOYMENT City of Henderson, N.C. AN EQUAL OPPORTUNITY EMPLOYER Instructions: Please fill out all sections of this application to the best of your ability. Your application will be used

More information

CHAPTER XI INSERVICE STATUS AND TRANSACTIONS

CHAPTER XI INSERVICE STATUS AND TRANSACTIONS CHAPTER XI INSERVICE STATUS AND TRANSACTIONS 11.01 Employment Data A. At the time of initial appointment, every regular (permanent or probationary) classified employee shall be provided with the following

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN TITLE: NUMBER: Reasonable Accommodation for Individuals with Disabilities BUL-4569.0 ROUTING All Employees All Locations ISSUER: David Holmquist, Chief Operating Officer Roberta Fesler, General Counsel

More information

Personal Information. Position you are applying for: Name Social Security Number - - Last First M.I. Address Street Apt.

Personal Information. Position you are applying for: Name Social Security Number - - Last First M.I. Address Street Apt. Last Name: First Name: MI: URBANDALE WATER UTILITY APPLICATION FOR EMPLOYMENT If you need help while completing this application form or during any phase of the employment process, please notify the Urbandale

More information

RetuRn to WoRk h a n d b o o k

RetuRn to WoRk h a n d b o o k Return to Work h a n d b o o k Return to Work h a n d b o o k Contents 1 > Introduction Definition, Purpose and Benefits of a Return-To-Work Program pg.2 2 > Creating and Implementing a Return-To-Work

More information

RETURN TO WORK POLICY. Introduction

RETURN TO WORK POLICY. Introduction RETURN TO WORK POLICY Introduction Humber College values the contributions its employees make to the overall goals and objectives of the College and is committed to providing a co-operative and pro-active

More information

9.1 Introduction Legislative requirements for JOHS Committees Composition of JOHS Committee and Safety Sub-committees...

9.1 Introduction Legislative requirements for JOHS Committees Composition of JOHS Committee and Safety Sub-committees... Table of Contents 9.1 Introduction... 2 9.2 Legislative requirements for JOHS Committees... 2 9.3 Composition of JOHS Committee and Safety Sub-committees... 2 9.4 Functions of JOHS Committee... 3 9.5 Roles

More information

INJURY AND ILLNESS PREVENTION PROGRAM

INJURY AND ILLNESS PREVENTION PROGRAM INJURY AND ILLNESS PREVENTION PROGRAM Dept: UNIVERSITY OF CALIFORNIA SANTA BARBARA Written Program Summary: UCSB Injury and Illness Prevention Program The IIPP is a Cal/OSHA regulation instituted in 1991.

More information

Workplace Safety Regulation

Workplace Safety Regulation State Guide to Workplace Safety Regulation Provided by: The Insurance House 205 South Market Marion, IL 62959 618-997-1311 www.inshouse.com Table of Contents Introduction: Illinois and Federal OSHA Regulations...

More information

THE UNIVERSITY OF TEXAS SYSTEM POLICE

THE UNIVERSITY OF TEXAS SYSTEM POLICE THE UNIVERSITY OF TEXAS SYSTEM POLICE PERSONAL HISTORY STATEMENT APPLICANT NAME POSITION Date Issued: Return By: Received On: CAUTION ANY INFORMATION REQUESTED IN THIS APPLICATION THAT YOU WILLFULLY MISREPRESENT,

More information

(Up to 12 weeks) SERIOUS INJURY OR ILLINESS OF A VETERAN FOR MILITARY CAREGIVER LEAVE

(Up to 12 weeks) SERIOUS INJURY OR ILLINESS OF A VETERAN FOR MILITARY CAREGIVER LEAVE (Up to 12 weeks) SERIOUS INJURY OR ILLINESS OF A VETERAN FOR MILITARY CAREGIVER LEAVE REQUEST FOR FAMILY MEDICAL LEAVE OF ABSENCE (FMLA) (up to 12 weeks) TABLE OF CONTENTS Medical Leave of Absence Requirements

More information

Return to Work Policy

Return to Work Policy Return to Work Policy It is the policy of the Raleigh County Board of Education to provide our workers injured on the job with the best possible recovery program so that they can return to work with minimal

More information

2. Policy. Employee management and disciplinary action practices at the University are subject to the following policies:

2. Policy. Employee management and disciplinary action practices at the University are subject to the following policies: 40-11 Employee Disciplinary Action and Termination 40-11-1 Purpose 40-11-2 Policy 40-11-3 Administration 40-11-4 Required Approval by the Office of Human Resources 40-11-5 Responsibilities and Rights 40-11-6

More information

SDML Workers' Compensation Fund Creating

SDML Workers' Compensation Fund Creating SDML Workers' Compensation Fund Creating A RETURN TO WORK PROGRAM INTRODUCTION: CREATING A RETURN TO WORK PROGRAM An early Return to Work program has proven to be highly effective in containing and reducing

More information

Strand Termite & Pest Control

Strand Termite & Pest Control Strand Termite & Pest Control PLEASE PRINT ALL 599 Seaside Rd SW, Ocean Isle Beach, NC 28469 910-579-9707 Phone 910-579-5150 Fax APPLICATION FOR EMPLOYMENT This Company is an equal employment opportunity

More information

FAMILY AND MEDICAL LEAVE POLICY

FAMILY AND MEDICAL LEAVE POLICY FAMILY AND MEDICAL LEAVE POLICY Policy It is the policy of Skidmore College to provide its employees time off (paid and unpaid) necessitated by illness or family care in accordance with the federal Family

More information

APPLICATION FOR EMPLOYMENT BRAYS ISLAND PLANTATION COLONY, INC. Brays Island is a Drug-Free Workplace

APPLICATION FOR EMPLOYMENT BRAYS ISLAND PLANTATION COLONY, INC. Brays Island is a Drug-Free Workplace PLEASE PRINT PLAINLY APPLICATION FOR EMPLOYMENT BRAYS ISLAND PLANTATION COLONY, INC. Brays Island is a Drug-Free Workplace Last Name First Middle Social Security No. Address Home Phone Business Phone Age

More information

Application for Employment

Application for Employment 30 Village Square Glendale, Ohio 45246 (513) 771-7200 glendale@glendaleohio.org Instructions: Please print and complete all questions. Application for Employment Applicant Identification: Date / / Name

More information

Reasonable Accommodations Committee (RAC) Procedures for Current Employees

Reasonable Accommodations Committee (RAC) Procedures for Current Employees Reasonable Accommodations Committee (RAC) Procedures for Current Employees The Americans with Disabilities Act of 990 (ADA) as amended by the ADA Amendments Act of 2008, hereafter (ADAAA), requires employers

More information

DEPARTMENT OF PHYSICAL PLANT Personnel Policy Guidelines

DEPARTMENT OF PHYSICAL PLANT Personnel Policy Guidelines Listed below, in bold type, are the infractions listed in Personnel Policies and Procedures for which all employees may receive disciplinary action. Under several of these statements are more specific

More information

Jackson Municipal Airport Authority Revenue-Payroll Accountant

Jackson Municipal Airport Authority Revenue-Payroll Accountant Jackson Municipal Airport Authority Revenue-Payroll Accountant This is a professional accounting position with heavy emphasis on payroll, revenue, and accounts receivable. Accounting functions include

More information

Jackson Municipal Airport Authority Director of Business Development, Marketing & Communications

Jackson Municipal Airport Authority Director of Business Development, Marketing & Communications Jackson Municipal Airport Authority Director of Business Development, Marketing & Communications The Director of Business Development, Marketing & Communications is responsible for overseeing the development,

More information

SHORT-TERM DISABILITY PROGRAM FREQUENTLY ASKED QUESTIONS

SHORT-TERM DISABILITY PROGRAM FREQUENTLY ASKED QUESTIONS SHORT-TERM DISABILITY PROGRAM FREQUENTLY ASKED QUESTIONS ELIGIBILITY / WHEN STD CAN BE USED Who is eligible to receive Short-Term Disability (STD) benefits? Chicago Public School Board employees who are

More information

1. To provide guidelines for disciplining classified employees in accordance with applicable laws, District policy, and Personnel Commission rules.

1. To provide guidelines for disciplining classified employees in accordance with applicable laws, District policy, and Personnel Commission rules. POWAY UNIFIED SCHOOL DISTRICT ADMINISTRATIVE PROCEDURE ARTICLE: 4.0 PERSONNEL SUPPORT SERVICES 4.3 CLASSIFIED PERSONNEL Originator: Issue No: Date: Page: Reference: Asst. Superintendent, PSS 2 7/29/91

More information

Bill 168: Violence and Harassment in the Workplace

Bill 168: Violence and Harassment in the Workplace Bill 168: Violence and Harassment in the Workplace On December 15, 2009, Bill 168, an Act to amend the Occupational and Safety Act with respect to violence and harassment in the workplace (the Bill ),

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION EMPLOYMENT APPLICATION As part of our normal procedure for processing applications, inquiries may be made concerning information on an applicant s work, driving, criminal and educational history. A pre-employment

More information

Biscuitville SUBSTANCE ABUSE POLICY

Biscuitville SUBSTANCE ABUSE POLICY Biscuitville SUBSTANCE ABUSE POLICY I. PURPOSE As a part of its commitment to safeguard the health of its employees, to provide a safe place for its employees to work and to promote a drug-free community,

More information

HAZARD IDENTIFICATION AND RISK ASSESSMENT Revision Date: 04/2017

HAZARD IDENTIFICATION AND RISK ASSESSMENT Revision Date: 04/2017 HAZARD IDENTIFICATION AND RISK ASSESSMENT 23.1 PURPOSE 23.1.1 The purpose of this policy is to help employees identify, analyze and apply control strategies to eliminate or reduce hazardous conditions

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT 2000 Territory Drive, Galena, IL 61036 815-777-2000 APPLICATION FOR EMPLOYMENT The Galena Territory Association, Inc. is an equal opportunity employer and does not discriminate on the basis of race, religion,

More information

Incident [Accident] Investigations

Incident [Accident] Investigations Incident [Accident] Investigations 1. Preserve/ Document Scene 2. Collect Information 3. Determine Root Causes 4. Implement Corrective Actions Objectives for Today Discuss the importance of why all incidents,

More information

Short Term Disability

Short Term Disability 3.1.10 Short Term Disability Policy Section: Leaves of Absence Policy Number and Title: 3.1.10 Short Term Disability Applicable to: All Benefits Eligible Employees Effective Date: January 1, 2012 Policy

More information

Accumulated Paid Leave: Includes FLSA compensatory time, sick leave, deferred holiday time, annual leave and state compensatory time.

Accumulated Paid Leave: Includes FLSA compensatory time, sick leave, deferred holiday time, annual leave and state compensatory time. GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: {x} All DJJ Staff { } Administration { } Community Services { } Secure Facilities (RYDC s and YDC s) Chapter 3: PERSONNEL Subject: WORKERS COMPENSATION

More information

NIAGARA FALLS ROWING CLUB VIOLENCE IN THE WORKPLACE PREVENTION POLICY

NIAGARA FALLS ROWING CLUB VIOLENCE IN THE WORKPLACE PREVENTION POLICY NIAGARA FALLS ROWING CLUB VIOLENCE IN THE WORKPLACE PREVENTION POLICY Policy The Niagara Falls Rowing Club is committed to providing a respectful, supportive, healthy, safe, accessible and inclusive work

More information

TITLE: Return-To-Work Policy

TITLE: Return-To-Work Policy TITLE: Return-To-Work Policy Worker s Compensation Early Return-To-Work Consistent with the general intent of Senate Concurrent Resolution 50 of the 1997 Regular Legislative Session, Senate Bill 689 of

More information

DRIVER APPLICATION FOR

DRIVER APPLICATION FOR DRIVER APPLICATION FOR 2630 S Jefferson Mt. Pleasant, TX 75455 Phones: (903) 572 1741 * 1-800-527-8616 Fax: 903-572-2798 * 1-888-527-8616 We are an Equal Opportunity Employer In compliance with Federal

More information

RETURN TO WORK GUIDELINES

RETURN TO WORK GUIDELINES RETURN TO WORK GUIDELINES PURPOSE: The Return to Work Program establishes a process for minimizing the impact of an illness or injury on the individual s capacity to participate constructively in the work

More information

Applicant s Name: Visit https://ecpic.commissionaires.ca/login/ to get a check done electronically.

Applicant s Name: Visit https://ecpic.commissionaires.ca/login/ to get a check done electronically. Welcome to the T.E.A.M.S. driver application process. Please fill out the application form completely do not leave any blank spaces where information is requested. If information requested does not apply,

More information

WORK PLACEMENT AGREEMENT

WORK PLACEMENT AGREEMENT WORK PLACEMENT AGREEMENT Thank you for choosing a Ravensbourne student for work placement. We hope the placement experience will be positive and that you will want to work with us on a continuing basis.

More information

BEDFORD PARK POLICE DEPARTMENT 6701 SOUTH ARCHER AVENUE BEDFORD PARK ILLINOIS PHONE FAX

BEDFORD PARK POLICE DEPARTMENT 6701 SOUTH ARCHER AVENUE BEDFORD PARK ILLINOIS PHONE FAX Selection Process Testing Order Candidates must successfully complete each test before advancing to the next phase of the selection process. The entire selection process may take several months. SELECTION

More information

ON-THE-JOB TRAINING AGREEMENT

ON-THE-JOB TRAINING AGREEMENT ON-THE-JOB TRAINING AGREEMENT Contract # 1. This On-the-Job Training (OJT) Agreement is between the Employer, the Trainee, and the OJT Agency. The three parties agree that the Employer shall hire the Trainee

More information

Agency Workers Compensation Handbook

Agency Workers Compensation Handbook Minnesota Department of Administration Risk Management Division Workers Compensation Program Agency Workers Compensation Handbook State of Minnesota Workers Compensation Program 310 Centennial Office Building

More information

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

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,

More information

NEW YORK STATE BAR ASSOCIATION. LEGALEase. Labor and Employment Law. New York State Bar Association 1

NEW YORK STATE BAR ASSOCIATION. LEGALEase. Labor and Employment Law. New York State Bar Association 1 NEW YORK STATE BAR ASSOCIATION LEGALEase Labor and Employment Law New York State Bar Association 1 What is Labor and Employment Law? This pamphlet is intended to provide Employers and Employees with general

More information

PLEASE ATTACH A RESUME AND COVER LETTER TO THIS APPLICATION. INCLUDE AT LEAST 5 REFERENCES. NAME: Last. First. Middle. Date ADDRESS + CONTACT: Street

PLEASE ATTACH A RESUME AND COVER LETTER TO THIS APPLICATION. INCLUDE AT LEAST 5 REFERENCES. NAME: Last. First. Middle. Date ADDRESS + CONTACT: Street Submit this completed application to mail@stalwork.com. An application, resume, cover letter, and references are required to be considered for employment. You may fax your completed paperwork to 805.542.0837

More information

MESA PUBLIC SCHOOLS. Information regarding the Family & Medical Leave Act and long-term leaves

MESA PUBLIC SCHOOLS. Information regarding the Family & Medical Leave Act and long-term leaves MESA PUBLIC SCHOOLS Information regarding the Family & Medical Leave Act and long-term leaves CONTENTS Introduction...1 Family and Medical Leave (FMLA)...2 Long-Term Health Leave...6 Intermittent Leave...8

More information

California State University

California State University California State University Office of the Chancellor Records Retention Guidelines for Employment-Related Records Human Resources Administration October 2004 Introduction... 1 Personnel Files... 1...1 s

More information

CONTRACTOR SAFETY MANAGEMENT PROGRAM (CSMP) PRE-QUALIFICATION SAFETY QUESTIONNAIRE

CONTRACTOR SAFETY MANAGEMENT PROGRAM (CSMP) PRE-QUALIFICATION SAFETY QUESTIONNAIRE CONTRACTOR SAFETY MANAGEMENT PROGRAM (CSMP) PRE-QUALIFICATION SAFETY QUESTIONNAIRE Omitting or reporting false information on this questionnaire could result in disqualification or removal from the Supplier

More information

GUIDELINES FOR Fitness for Duty

GUIDELINES FOR Fitness for Duty GUIDELINES FOR Fitness for Duty Examinations Employer-Employee Relations Human Resources Division July, 2006 CONTENTS Introduction... 1 What is Fitness for Duty?...1 Returning from Leave....1 Health Concern...1

More information

Contact Information. Emily Morlan Indiana Department of Labor INSafe Division Safety Consultant (317)

Contact Information. Emily Morlan Indiana Department of Labor INSafe Division Safety Consultant (317) Contact Information Emily Morlan Indiana Department of Labor INSafe Division Safety Consultant (317)-234-4681 emorlan@dol.in.gov Curtis Taylor Indiana Department of Labor INSafe Division Health Consultant

More information

Introduction. Module Objective

Introduction. Module Objective Introduction Managing Safety and Health Time: About two hours, Objectives: 1: Explain the importance of an effective health & safety program 2: Explain worker rights to a safe & healthful workplace 3:

More information

OATH OF ALLEGIANCE NEW EMPLOYEES.

OATH OF ALLEGIANCE NEW EMPLOYEES. LOS ANGELES COMMUNITY COLLEGES BOARD RULES, CHAPTER X, ARTICLE I HUMAN RESOURCES SERVICES 10101. UNSOLICITED WRITTEN DEROGATORY COMMUNICATIONS. The Chancellor shall establish and maintain administrative

More information

Obtaining and responding to medical information in the workplace: A summary for employers

Obtaining and responding to medical information in the workplace: A summary for employers Obtaining and responding to medical information in the workplace: A summary for employers ADR2013 Introduction The Alberta Human Rights Commission offers a detailed interpretive bulletin called Obtaining

More information

Application to the Virginia BEST

Application to the Virginia BEST Application to the Virginia BEST LEVEL I Applicants Submitted to: Associated General Contractors of Virginia Virginia BEST Program 11950 Nuckols Rd. Glen Allen, VA 23059 Attn: Mr. Gordon Dixon Company

More information

THE CITY UNIVERSITY OF NEW YORK THE CATASTROPHIC SICK LEAVE BANK PROGRAM. The Catastrophic Sick Leave Bank Program

THE CITY UNIVERSITY OF NEW YORK THE CATASTROPHIC SICK LEAVE BANK PROGRAM. The Catastrophic Sick Leave Bank Program I. Program Description THE CITY UNIVERSITY OF NEW YORK THE CATASTROPHIC SICK LEAVE BANK PROGRAM The Catastrophic Sick Leave Bank Program The Catastrophic Sick Leave Bank ( CSLB ) is a pool of sick leave

More information

Phone Fax

Phone Fax Please fill out application completely, even if your resume is attached. : Today s Date LAST FIRST MIDDLE : Street: City: State: Zip: ( ) ( ) ( ) Cell Phone Home Phone Business Phone Social Security Number

More information

Application for Employment

Application for Employment Application for Employment By completing and submitting this application for employment, I UNDERSTAND AND ACKNOWLEDGE THAT, UNLESS OTHERWISE DEFINED BY APPLICABLE LAW, ANY EMPLOYMENT RELATIONSHIP WITH

More information

No. HR Page 1 of 5 Effective Date: 08/31/15

No. HR Page 1 of 5 Effective Date: 08/31/15 TEXAS STATE TECHNICAL COLLEGE STATEWIDE OPERATING STANDARD No. HR 2.4.1 Page 1 of 5 Effective Date: 08/31/15 DIVISION: SUBJECT: Human Resources Employee Corrective Action AUTHORITY: Minute Order #06-13

More information

DRIVER APPLICATION COMPANY DRIVER

DRIVER APPLICATION COMPANY DRIVER 45 Fernwood Ave Edison New Jersey 08837 T: (732) 346-6666 - F: (732) 225-2090 W: www.mx logistics.com DRIVER APPLICATION COMPANY DRIVER (Answer all questions please print) In compliance with Federal and

More information

HR COMPLIANCE CHECKLIST HIRING PRACTICES

HR COMPLIANCE CHECKLIST HIRING PRACTICES HR COMPLIANCE CHECKLIST This checklist features key steps for evaluating your practices in order to keep your bank HR compliant. i HIRING PRACTICES All job postings and advertisements include the bank

More information

Lacombe & District FCSS HOME SUPPORT PROGRAM Employee Guidelines

Lacombe & District FCSS HOME SUPPORT PROGRAM Employee Guidelines Lacombe & District FCSS HOME SUPPORT PROGRAM Employee Guidelines June 2011 1 Hiring Procedures All Home Support Providers (employees) are expected to adhere to the policies set out in the Lacombe and District

More information

CORPORATE POLICY SUBSTANCE ABUSE POLICY SCOPE

CORPORATE POLICY SUBSTANCE ABUSE POLICY SCOPE ORIGINAL EFFECTIVE: REVISION NO. REVISION EFFECTIVE: CORPORATE POLICY POLICY NO. PAGE NO. 1 SUBSTANCE ABUSE POLICY SCOPE This policy applies to all* regular status full-time and part-time employees of

More information

SUBCONTRACTOR MANAGEMENT

SUBCONTRACTOR MANAGEMENT Doc : Revision. 0 Preparation: Safety Mgr Authority: Director Issuing Dept: Safety Page: Page 1 of 9 Purpose The purpose of this program is to ensure that ANC Foster continues to improve subcontractor

More information

FMLA, Disability and Workers Compensation

FMLA, Disability and Workers Compensation FMLA, Disability and Workers Compensation Understanding the benefits and the process This is intended to be a general description of benefits. Be sure to refer to the CU HR Policy Manual for details http://hr.columbia.edu/policies/hr-manual/time-away-work.

More information

SFCC EMPLOYEE CORRECTIVE ACTION AND DISCIPLINARY ACTION POLICY 4-2

SFCC EMPLOYEE CORRECTIVE ACTION AND DISCIPLINARY ACTION POLICY 4-2 SFCC EMPLOYEE CORRECTIVE ACTION AND DISCIPLINARY ACTION POLICY 4-2 Policy Overview SFCC strives to provide a safe and harmonious work environment where employees are able to perform their work productively

More information

DRUG FREE WORKPLACE. Objective: To provide a safe and healthful environment for patients and employees.

DRUG FREE WORKPLACE. Objective: To provide a safe and healthful environment for patients and employees. Objective: To provide a safe and healthful environment for patients and employees. Policy: UHS policy prohibits the unlawful use, manufacture, possession, distribution or dispensing of drugs ("controlled

More information

Central Oregon Community College Manufacturing and Applied Technology Center MFG 280 COOPERATIVE WORK EXPERIENCE GUIDE FOR STUDENTS

Central Oregon Community College Manufacturing and Applied Technology Center MFG 280 COOPERATIVE WORK EXPERIENCE GUIDE FOR STUDENTS Central Oregon Community College Manufacturing and Applied Technology Center MFG 280 COOPERATIVE WORK EXPERIENCE GUIDE FOR STUDENTS Manufacturing and Applied Technology Center 2030 College Loop Redmond

More information

GENERAL HUMAN RESOURCES AND PAYROLL ADMINISTRATION PROCEDURES

GENERAL HUMAN RESOURCES AND PAYROLL ADMINISTRATION PROCEDURES GENERAL HUMAN RESOURCES AND PAYROLL ADMINISTRATION PROCEDURES PURPOSE: To provide information and direction to employees regarding human resources and payroll processes and procedures and to ensure efficiency

More information

ENVIRONMENT, HEALTH & SAFETY POLICY Up date

ENVIRONMENT, HEALTH & SAFETY POLICY Up date ENVIRONMENT, HEALTH & SAFETY POLICY Up date 2017-07-03 1.0 PURPOSE Exo-s is vitally interested in the environment, health and safety of its employees. Protection of employees from injury or occupational

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT COMPANY STREET ADDESS CITY, STATE AND ZIP CODE NAME (FIRST) (MIDDLE) (MAIDEN IF ANY) (LAST) ADDRESS HOW LONG? (STREET) (CITY) (STATE & ZIP CODE) DATE OF BIRTH SOCIAL SECURITY

More information

Safety Pages: Gasoline Safety... P. 2-3 Saw Safety... P. 4-5 Posting Requirements... P and Illnesses rule... P

Safety Pages: Gasoline Safety... P. 2-3 Saw Safety... P. 4-5 Posting Requirements... P and Illnesses rule... P February 2017 February, 2017 : Gasoline Safety... P. 2-3 Saw Safety... P. 4-5 Posting Requirements... P. 6-9 Safety Article: Oregon OSHA adopts changes to the Recording Workplace Injuries and Illnesses

More information

ACCIDENT REPORT COMPLETION GUIDELINES

ACCIDENT REPORT COMPLETION GUIDELINES ACCIDENT REPORT COMPLETION GUIDELINES The following guidelines are to assist managers in completing the Accident Report. Definitions: 1. Accident: Any adverse effect relating to people, property, the process

More information

CIRCLE TYPE OF EMPLOYMENT DESIRED: Full Time Part Time Full or Part Time Substitute. FULL NAME: Last First Middle

CIRCLE TYPE OF EMPLOYMENT DESIRED: Full Time Part Time Full or Part Time Substitute. FULL NAME: Last First Middle CLINTON COMMUNITY SCHOOLS APPLICATION FOR 1401 12 th Ave. No. SECRETARY Clinton, Iowa 52732 (563)243-0463 FAX: (563)243-0493 POSITION APPLIED FOR: http://www.clinton.k12.ia.us DATE OF APPLICATION: CIRCLE

More information

Review Responsibilities: Human Resources

Review Responsibilities: Human Resources Family Medical Leave Act (FMLA) Review Responsibilities: Human Resources Policy Number: RH-HR-HR-60-06-11 Effective Date: December 2007 I. Purpose II. Origination Date: April 1995 To comply with the provisions

More information

PHRca Exam Preparation Final Assignment

PHRca Exam Preparation Final Assignment Your final assignment is to answer the 60 essay questions below. You have unlimited time to complete the assignment as long as it is completed by the last day of class. The assignment is open book. Please

More information

Corporate Safety Manual. Chapter 18 Employee s Notice of Safety Non-Compliance

Corporate Safety Manual. Chapter 18 Employee s Notice of Safety Non-Compliance Corporate Safety Manual Chapter 18 Employee s Notice of Safety Non-Compliance Last updated: April 2015 Employee s Notice of Safety Non-Compliance Chapter 18: Employee s Notice of Safety Non-Compliance

More information

Town of Franklin EMPLOYMENT APPLICATION An Equal Opportunity Employer

Town of Franklin EMPLOYMENT APPLICATION An Equal Opportunity Employer Town of Franklin EMPLOYMENT APPLICATION An Equal Opportunity Employer Fill out all sections COMPLETELY and to the best of your ability. Your application will be used as part of the examination process

More information

U.S. Department of Labor

U.S. Department of Labor U.S. Department of Labor Employment Standards Administration Wage and Hour Division Employment Standards Administration Wage and Hour Division FMLA Compliant Guide The Family and Medical Leave Act The

More information

2016 Employee Benefits Webinar Series An Employer s Guide to FMLA and COBRA

2016 Employee Benefits Webinar Series An Employer s Guide to FMLA and COBRA 2016 Employee Benefits Webinar Series An Employer s Guide to FMLA and COBRA February 18, 2016 Stacy H. Barrow Marathas Barrow & Weatherhead LLP sbarrow@marbarlaw.com Agenda Family Medical Leave Act (FMLA)

More information

3 14. Drug Abuse and Controlled Substances

3 14. Drug Abuse and Controlled Substances 3 14. Drug Abuse and Controlled Substances Vectrus will not tolerate illegal drugs, controlled substances or alcohol abuse and will take all reasonable steps to ensure that drug and alcohol abuse does

More information

EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT

EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT EMPLOYEE ENTITLEMENT An eligible employee may take up to twelve weeks (26 weeks to care for a covered servicemember with a serious

More information

SECTION 2 RECRUITMENT, SELECTION, APPOINTMENT RECRUITMENT: Department of Job & Family Services 2.05 EMPLOYMENT ELIGIBILITY

SECTION 2 RECRUITMENT, SELECTION, APPOINTMENT RECRUITMENT: Department of Job & Family Services 2.05 EMPLOYMENT ELIGIBILITY SECTION 2 RECRUITMENT, SELECTION, APPOINTMENT 2.01 RECRUITMENT 2.02 RECRUITMENT: Department of Job & Family Services 2.03 SELECTION 2.04 SELECTION PROCESS RECORDKEEPING 2.05 EMPLOYMENT ELIGIBILITY 2.06

More information