Summary This procedure is for reporting Industrial Injuries. The verbiage (Industrial Injuries) used in this procedure includes, but may not be limited to: injuries, exposure to harmful materials, and diseases. The following will walk you through the steps necessary to report an industrial injury for all employees covered under a policy manual as well as student workers, adjunct faculty, temporary employees and official volunteers. This includes filing the report, time and labor reporting, and workers compensation benefits. The supervisor and Public Safety/Workers Compensation campus representative are responsible for the following procedures. These procedures exclude student injuries. Contact Public Safety for student injury procedures. Industrial Injury on Campus Employee must report the injury to their supervisor at the time of the accident. If there is not a supervisor available, Contact Public Safety/Workers Compensation campus representative. The employee must receive the proper authorization form before seeking medical treatment. (Form A or Form B) The employee has a choice of two industrial medical centers: Concentra or U.S. Health Works. Dial 911 for any life threatening accident/situation. The supervisor then completes the Supervisor s Report of Industrial Injury. (Form C) This report must be completed in its entirety and given to Public Safety/Workers Compensation campus representative within 24 hours of the injury. The Supervisor s Report of Industrial Injury must be completed even if the employee does not seek medical treatment. Public Safety/Workers Compensation campus representative then completes the Industrial Commission of Arizona (ICA101) report. (Form D) The ICA101 report must be completed even if the employee does not seek medical treatment. Public Safety/Workers Compensation campus representative will then submit the Supervisor s Report of Industrial Injury and the ICA101 report to District Risk Management within 48 hours of the injury. Industrial Injury off campus while on MCCCD Business If medical treatment is needed, go to the nearest industrial medical center. If medical treatment is needed outside of Arizona, go to the nearest urgent medical center. Dial 911 for any life threatening accident/situation. Once the employee returns to work, the employee must report the injury to their supervisor immediately. If the supervisor is not available, contact Public Safety/Workers Compensation campus representative. At the time the injury is being reported the employee must submit copies of all medical documents. In the event physical contact can not be made with the employee within 24 hours the supervisor needs to contact the employee by phone and/or e-mail to complete the Supervisor s Report of Industrial Injury. (Do not hold paperwork pending the injured worker s signature) Campus s Page 1
The supervisor then completes the Supervisor s Report of Industrial Injury (Form C). This report must be completed in its entirety and given to Public Safety/Workers Compensation campus representative within 24 hours of the injury. Medical documents need to be attached to the Supervisor s Report of Industrial Injury. The Supervisor s Report of Industrial Injury must be completed even if the employee does not seek medical treatment. Public Safety/Workers Compensation campus representative then completes the Industrial Commission of Arizona (ICA101) report (Form D). The ICA101 report must be completed even if the employee does not seek medical treatment. Public Safety/Workers Compensation campus representative needs to submit the Supervisor s Report of Industrial Injury and the ICA101 report to District Risk Management. If employee receives work restrictions/modified work duties following the injury The supervisor will determine if the work restriction/modified work duties can be met. If work restrictions/modified work duties cannot be met, District Risk Management needs to be notified. If work restrictions/modified work duties can be met, District Risk Management needs to be notified. o Light duty requirements must be done at the college. Light duty from home is not permitted. o Employees are not eligible for contract pay when on an Industrial Leave of Absence. Thirty (30) Days Paid Benefit Rule: Any employee that is covered by a policy manual and is absent due to an industrial accident resulting in injury or illness to the employee will be allowed up to thirty (30) days of absences without loss of pay and without loss of current or accumulated sick leave. The industrial claim must be accepted by the third party claims administrator. Eligible employee: Any employee covered under a policy manual Non-Eligible employee: Time card employees, one year only employees An employee is eligible for the thirty (30) days period per accepted industrial claim. The absence code that tracks these absences is IND. Time and Labor Reporting Date of Injury On the date of injury the employee will be paid their regular earnings as usual. The IND code will be used to document the date of injury. The IND code is used to track attendance only and will not deduct from the employees accruals. Example: Employee is accountable for 8 hours on the date of injury and will be paid those hours. However, the employee was at Concentra for 3 hours of the 8 accountable hours, the IND code needs to read: IND 3.0. Campus s Page 2
No return to work/unable to meet restriction/modified work duties If the employee has orders not to return to work or if the supervisor is unable to meet the work restriction/modified work duties, the supervisor needs to contact District Risk Management prior to reporting time to determine if the worker is entitled to the thirty (30) days paid benefit. Not eligible for thirty (30) days paid benefit. If the employee is not eligible for the thirty (30) days paid benefit, on the day following the date of injury the ISC code will be used to document hours missed for one year only (OYO) employees. The ISC code will deduct from the employee s sick accruals. (This means the claim was approved but the employee is not covered under a policy manual and therefore not entitled to the 30 days paid benefit.) If the employee is a time card employee the supervisor will track their time manually and email this information to District Risk Management. Eligible for thirty (30) days benefit. If the employee is eligible for the thirty (30) days paid benefit, on the day following the date of injury the IND code will be used to document the hours missed up to thirty (30) days. The IND code is used to track attendance only and will not deduct from the employee s sick accruals. Return to work/able to meet restriction/modified work duties If work restrictions/modified work duties are being met no code needs to be used in Time and Labor. If time is missed due to doctor s appointments after the employee has been released to duty the ISC code must be used. This will deduct from the employees sick accruals and should be used for industrial injury related appointments only. Please Note: Vacation and Banked Vacation can not be used to cover industrial injury related appointments. The employee must use sick time only. Time card employees will not be paid for time missed due to industrial related injury appointments after a release to duty has been issued. Campus s Page 3
Form A Campus s Page 4
Form B Campus s Page 5
Form C Campus s Page 6
Form C - Page 2 Campus s Page 7
Form D Campus s Page 8
Example for College Safety/Worker s Compensation Campus Rep. Green Campus completes Red District Office completes Campus s Page 9