WSIB / WCB / CNESST Instructions

Transcription

1 WSIB / WCB / CNESST Instructions 1. Report the injury / illness immediately to your manager / acting manager. Obtain first aid / emergency assistance, as needed. Report any health care received on the same day to your manager. 2. Bring the functional abilities form (FAF) or Temporary Assignment (TA) form (Quebec only) to your healthcare provider and have it completed. Return to work to submit the FAF / TA form to your manager prior to your next scheduled shift. Please te: a doctor s te is t sufficient documentation. 3. Participate in work per your functional capabilities and cooperate with your return to work plan in accordance with timelines. 4. Return to full duties, as of the date indicated on the Transitional Return to Work Plan (TRTWP) Encl.: Letter to Employee Modified Work Letter to Treating Healthcare Provider Functional Abilities Form (FAF) & Invoice Temporary assignment Form (Quebec only) Worker s Report of Injury Phone: OSI4FedEx@orgsoln.com Fax:

2 Date: Dear Employee: FedEx Express Canada (FedEx) recognizes our most valuable resource is our employees and we are committed to assisting in the health, safety and well-being of all employees. FedEx Express Canada has a formal Timely and Safe Return to Work program in place for employees who are recovering from a work related injury / or illness in accordance with the requirements of the WSIB / WCB / CNESST. FedEx Express Canada has retained the services of Organizational Solutions Inc. (OSI) to provide support to our employees. OSI is a leading care management company assisting FedEx Express Canada with the management of our work related injuries / illnesses. Under workers compensation legislation, we have an obligation to offer you modified duties based on your functional abilities information. You have an equal obligation to cooperate in your timely return to work including having the enclosed Functional Abilities Form (FAF) or Temporary Assignment (TA) form (Quebec only) completed in full by your health care provider. Please be advised that FedEx will pay for the completion of the FAF. The CNESST covers all costs related to the TA form. Please check the employee s area of injury and te the following tasks which are immediately available: Back Shoulder Knee Neck Elbow / Forearm Ankle Wrist / Hand Other Operations Operations Ramp Answering station phones Paperwork - filing, auditing of paperwork, scanning, photocopying Genesis (computer work) Customer greeter, assist customers with the completion of waybills Training Recurrency / Safety / SkillSoft) (computer based work) Data Entry Quality Improvement Memos (paperwork, computer work) Updating bulletin boards Safety inspections with JHSC Shuttle driving Front counter activity (talk to customers, answering phones, computer work) Cleaning trucks Vehicle audits (paperwork / document review) Calling customers to update / verify addresses Ride along with new driver assisting with deliveries per capabilities CSR Station duties works on undeliverable packages (computer work, phone calls) Scans packages for sort (hand held device) Helps with station courier check-in / hand out hand held trackers Scanning packages and documents Paperwork auditing Gatekeeper back up (hands out hand held trackers / checks in equipment) Deck Loader Operator (paperwork, package handling, driving, aircraft marshalling) Guard Duty (ensuring visits are recorded) Training Recurrency / Safety / SkillSoft) (computer based work) Please be advised, the WSIB / WCB / CNESST may t award benefits if appropriate modified duties are provided, and you do t participate in a timely and safe return to work. Once the FAF / TA form has been completed and returned, additional specific modified duties may be assigned. A chair will be provided to you; if required. Micro stretch / ice breaks can be taken as required. All duties will be self-paced. If you have any questions, please contact your Manager or Organizational Solutions Inc., Offer Confirmation: I have read and understand modified work is available within my physical abilities / restrictions, and I am obligated to return to work immediately. I accept the offer of modified duties I decline the offer of modified duties Employee Signature Date Sincerely, FedEx Express Canada Management Encl.: Letter for Treating Health Care Provider, FAF/Temporary Assignment form & Invoice and Worker s Report of Injury Phone: OSI4FedEx@orgsoln.com Fax:

3 Dear Treating Healthcare Provider: FedEx Express Canada is committed to providing suitable, medically supported assistance to employees in their recovery and safe return to work. FedEx Express Canada has a Timely and Safe Return to Work Program and is willing to provide transitional modified duties and / or modified hours of work. Employees must provide sufficient documentation to support their absence. The documentation should include the employee s abilities and limitations and will be used to develop a modified work plan. A Workers Compensation Specialist at Organizational Solutions Inc. (OSI) will work with your patient to support and help him / her during their recovery and return to work. The employee s functional capabilities / restrictions will be shared with FedEx Express Canada. In order for FedEx Express Canada to facilitate a Timely and Safe Return to Work Plan (when an employee has reported a work related injury / illness), and ensure that your patient returns to suitable work in a timely manner in accordance with the Workers Compensation Act, we require completion and submission of the enclosed Functional Abilities Form or Temporary Assignment form (Quebec only) within 24 hours. We thank you in advance for your assistance and invite you to contact us at should you have any questions. Sincerely, Workers Compensation Specialist Organizational Solutions Inc. Encl.: Functional Abilities Form / Temporary Assignment Form Invoice Please Note: The treating physician s role in helping a patient return to work has the following main elements: providing to the patient medical necessary services related to the injury or illness to achieve optimum health and functionality; providing objective, accurate and timely medical information for the consideration of eligibility of insurance benefits; and providing objective, accurate and timely medical information as part of the timely return-to-work program. CMA The Treating Physician s Role in Helping Patients Return to Work After an Illness or Injury (Update 2013).

4 Functional Abilities Form for Timely Return to Work Employee Name: Phone #: Job Title: Hours: FT PT Hours / Days Rotation: AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize health care provider(s), institutions, or the WSIB / WCB / CNESST involved in my treatment or claim to discuss and provide all information and documents requested by FedEx and Organizational Solutions Inc., concerning my current medical or psychological health condition. I authorize Organizational Solutions Inc. to release information to the WSIB / WCB / CNESST, Insurance Company, administrators of government benefits, or health care practitioners and my employer. I agree that an electronic facsimile or a photo copy is to be considered as valid as an original signed copy. Employee s Signature: Date: / / Month Day Year Initial Diagsis: Occupational Occupational Recurrence Non Occupational Return to regular duties? Yes No If, please complete the following section: PLEASE COMPLETE WHERE LIMITATIONS ARE RECOMMENDED: A. SITTING / STANDING / WALKING Occasional (1-33%) Frequent (34-66%) No Limitations Comments Sitting Standing Walking Crawling B. LIFTING FLOOR TO WAIST Sedentary (up to 4.5kgs) Light ( kgs) Medium ( kgs) Heavy ( kgs) LIFTING WAIST TO SHOULDER Sedentary (up to 4.5kgs) Light ( kgs) Medium (9.1 22kgs) Heavy ( kgs) LIFTING ABOVE SHOULDER Sedentary (up to 4.5kgs) Light ( kgs) Medium (9.1 22kgs) Heavy ( kgs) C. UPPER BODY Left Right Both Left Right Both Left Right Both Pushing / Pulling Carrying Gripping Reaching Forward (over 45 cm) Reaching Overhead (over 178 cm) Deviated Wrists D. LOWER BODY REQUIREMENTS Occasional (0 33%) Frequent (34 66%) No Limitations Kneeling Bending / Twisting Stair / Ladder Climbing E. Operating Motorized Equipment No Limitations Limitations reported to Ministry of Transportation F. Remarks: Date RTW Modified Work: Date RTW Regular Job: Estimated Duration of Limitations: Date of Next Appointment: By completing this Functional Abilities Form, the information contained herein will become part of the employee health file and may be accessed by the patient (injured worker), WSIB / WCB / CNESST, Insurance Company, third party administrator, or other health care professionals, the employer, as applicable. FedEx has modified work available. Please have the employee return this form immediately to FedEx. Health Professional Name: Health Profession: Fax Number: ( ) (please print) Full Address: City/ Town: Prov.: Signature: Date: Telephone: ( ) Phone: OSI4FedEx@orgsoln.com Fax:

5 Invoice Number: INVOICE To: Organizational Solutions Inc. Fax: / Date: FedEx FAF Total: $45 Patient / Employee Name: Date Service Provided: Name of Healthcare Provider: Address: Phone #: Please Make Cheque Payable to: Please print Phone: / OSI4FedEx@orgsoln.com Fax: /

6 Mail To: Workplace Safety and Insurance Board 200 Front Street West Toronto ON M5V 3J1 OR Fax To: OR Worker's Report of Injury/Disease (Form 6) Claim Number Please PRINT in black ink A. Worker Information Last Name First Name Social Insurance Number Address (number, street, apt., suite, unit) Telephone City/Town Province Postal Code Alternate/Cell Phone Job Title/Occupation (at the time you were hurt) Only check if you are one of the following: Sex M Your Preferred Language F English French Date you started with employer dd mm yy executive elected official owner spouse or relative of the employer Other How long have you been doing this job for this employer? Date of Birth Would an interpreter be helpful? dd mm yy Are you a member of a union? Do you authorize your union to represent you If, do you consent to the disclosure of verbal claim in this claim? file status information to your union representative? Provide your Union Name and Local B. Employer Information Company/Employer Name Address City/Town Province Postal Code Your Immediate Supervisor's Name Company Telephone C. Accident/Illness Dates & Details 1. Date and hour of accident/awareness of illness Date and hour reported to employer dd mm yy AM PM dd mm yy AM PM 2. Who did you report this accident/illness to? (Name & Position) Telephone 3. Area of Injury (Body Part) - (Please check all that apply) Head Teeth Upper back Face Neck Lower back Eye(s) Chest Abdomen Ear(s) Pelvis Left Right Left Right Left Right Left Right Shoulder Wrist Hip Ankle Arm Hand Thigh Foot Elbow Finger(s) Knee Toe(s) Forearm Lower Leg Are you: Other: Left Handed Right handed 4. Did the accident/illness happen on the employer's property or work site? Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.): 5. Did it happen outside the Province of Ontario? If, indicate where (city, province/state, country): 6. Have you hurt this area(s) of your body before? 7. Do you have any prior - In Ontario - Outside Ontario related WSIB/WCB claims? A guide to complete this form is available at A (02/13) Page 1 of 3

7 Worker Name - Last Name Please PRINT in black ink First Name 6 Worker's Report of Injury/Disease (Form 6) Claim Number Social Insurance Number C. Accident/Illness Dates & Details (continued) 8. If you had a sudden type of accident/illness, describe your injury and what happened to cause it (e.g. hurt lower back while lifting a 50 pound box, sprained left ankle when I slipped on a wet floor, used a new cleaner and immediately got a rash). Please indicate the size, weights and names of any objects involved. or If you had a gradual onset type of injury, describe your injury, the work that you do and what you believe caused your injury/condition. 9. When did you first start to have problems with this injury/condition? 10. If you did t report this to your employer right away, please tell us the reason why. 11. If there were any witnesses to your accident, or if you mentioned your pain or problems to your supervisor or any of your co-workers, give us their names & positions Name Position 12. The Workplace Safety and Insurance Act requires your employer to give you a copy of the Employer's Report of Injury/Disease (Form 7). Did you receive a copy of the Form 7? D. Health Care Information 1. Did you get first aid or care at work The Workplace Safety and Insurance Act requires you to give a copy of this report (Worker's Report of Injury/Disease - Form 6) to your employer. If, when Give your Health Professional your WSIB Claim number. dd mm yy and by whom (Name): 2. Where did you go for health care, for your injury, outside of work? (Check all that apply) Nursing Station Emergency Department Admitted to Hospital Facility/Hospital (Name & Address) Date of Visit (dd/mm/yy) Ambulance Health Professional Office Clinic Date of Visit (dd/mm/yy) 4. Were you referred for any other treatment or tests? 3. Were you prescribed any medications/drugs? 5. Did you talk to your health professional about going back to regular or modified work? 6. Did you tell your employer you went for medical treatment? dd mm yy Name If, were you given any work limitations? If, please tell your employer right away. If, when? and to whom? Position 0006A2 (02/13) Page 2 of 3

8 Worker Name - Last Name Please PRINT in black ink First Name 6 Worker's Report of Injury/Disease (Form 6) Claim Number Social Insurance Number E. Lost Time & Return to Work 1. After the day of accident/illness: I returned to work to my regular job and did t lose any time or pay. I returned to modified duties and did t lose any time or pay. I lost time and/or pay (e.g. regular pay, shift differential, bonuses, premiums, etc.). υ Date you first lost time and/or pay dd mm yy 2. If you lost time, have you returned to work? dd mm yy If Date of your return to work regular work modified work υ If υ Did you discuss return to work with Does your employer have modified work? your employer? F. Earnings (Do t include overtime here) 1. Rate of pay: per hour week other: $ 2. Usual number of pay hours: per week other: 3. If you lost time from work after the day of accident/illness, did your employer continue to pay you? 4. Have you applied for, or did you receive, any other benefits (money) while off work (e.g. EI benefits, sick benefits, social services, insurance, etc.). 5. At the time of the accident/illness did you work for more than one employer? G. Declarations and Signature By signing below, I am claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related injury or disease. I am also authorizing any health professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board with information about my functional abilities on the WSIB's "Functional Abilities Form for Planning Early and Safe Return to Work". It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board. I declare that all of the information provided on pages 1, 2, and 3 is true. Signature Date (dd/mm/yy) If you are under the age of 16, your parent or guardian, must authorize the release of the functional abilities information. Signature Relationship: Date (dd/mm/yy) Telephone ( ) Personal information about you will be collected throughout your claim under the authority of the Freedom of Information and Protection of Privacy Act and will be used to administer the Workplace Safety and Insurance Act, 1997, your claim(s) and programs of the Board. Medical and n-medical information is collected from health care providers, vocational agencies, labour market service providers, employers, witnesses, Canada Revenue Agency (CRA), and others as required. Your Social Insurance Number is used to register claims, identify workers and to issue income tax receipts and is collected under the authority of the Income Tax Act. Information may only be disclosed to the employer, external medical, vocational, and safety agencies, external payment and service providers, researchers, and others as authorized by the Workplace Safety and Insurance Act and the Freedom of Information and Protection of Privacy Act. Your name and telephone number may be disclosed to third party researchers conducting satisfaction surveys and focus groups. Incoming and outgoing calls may be recorded for quality assurance purposes. Questions should be directed to the decision maker responsible for your file or toll free at A more detailed PRIVACY STATEMENT for workers may be found at or by calling toll free at A3 (02/13) Page 3 of 3

9 Worker Name - Last Name Please PRINT in black ink First Name 6 Worker's Report of Injury/Disease (Form 6) Claim Number Social Insurance Number K. Additional Information 0006A4 (02/13) The Workplace Safety & Insurance Act requires you to give a copy of this report (Worker's Report of Injury/Disease - Form 6) to your employer