workers’ compensation instruction booklet

WORKERS’ COMPENSATION

INSTRUCTION BOOKLET

SEMINOLE COUNTY PUBLIC SCHOOLS

RISK MANAGEMENT DEPARTMENT

www.scps.k12.fl.us

(Risk Management Department)

2015-2016

1 (Revised July 2015)

TABLE OF CONTENTS

Page Title of Forms

1 Table of Contents

2 Workers’ Compensation Important Numbers

3-5 Instructions for Processing a Workers’ Compensation Report of Injury or Illness

6-7 First Report of Injury or Illness (Available electronically upon request)

8 Notification Form

9 Medical Providers List

10 Medical Report for Treatment Form

11 PMOA Workers’ Compensation Prescription Information Form

12 Participating Pharmacies List

13 Choice Form

14 Temporary Staffing Employment Agencies

15 Important Reminders


WORKERS’ COMPENSATION IMPORTANT NUMBERS

Florida School Boards Insurance Trust (FSBIT)

Post Office Box 10709

Tallahassee, Florida 32302-2709

Main Number: (850) 414-0818 x “327”

Toll Free Number: (800) 790-2118 x “327”

Fax: 850-414-0893

JoAnneMcBrayer (WC Claims)(Last Names A-G)

[email protected], Extension 314

Krista Casey (WC Claims Only) (Last Names H-Z)


Rhonda Brock, RN (Nurse Case Manager)


Todd Scott (Property & Casualty Adjuster)


Linda Quick (C.F.O/Coordinator of Business Services)


James D. Barnidge (Claims Manager/Coordinator of Loss Prevention Services)


David Stephens (Director of Risk Management)


Seminole County School Board

Risk Management Department

David R. Apfelbaum, Director

(407) 320-0208

Dawn Lobkovich, Executive Secretary

(407) 320-0242

Fax: (407) 320-0411

mailto:[email protected]








INSTRUCTIONS FOR PROCESSING A WORKERS’ COMPENSATION REPORT OF INJURY OR ILLNESS

FOR SEMINOLE COUNTY PUBLIC SCHOOLS

1. When an employee reports that he/she has suffered a work related injury, the employee must complete a First Report of Injury or Illness form, Form DFS-F2-DWC-1 (this includes employees working through a temporary staffing employment agency, see page 14). If the employee cannot sign or fill out the form, the workers’ compensation contact is to complete the form to the extent of known information.

2. The First Report of Injury or Illness form must be completed using the electronic Word template. The employee has to provide the information necessary to complete the electronic form. The employee must designate the date on which the injury

occurred and/or the claimed condition or illness manifested. The cost center workers’

compensation contact should not assist the employee in determining what date

is to be used. The workers’ compensation contacts must print the electronic form and have the employee review and sign the form. 3. The workers’ compensation contact must keep the original signed form in the injured employee’s workers’ compensation file at the cost center. Again, if the employee cannot sign the First Report of Injury or Illness form, the signature box,

located on the bottom of the form is to be marked “not available at this time.” An

amended form is to be completed as soon as the injured employee is able to sign. A copy of the form should be given to the cost center supervisor, as well as any medical work status information received by a doctor. 4. The completed First Report of Injury or Illness form for employees should then

be emailed to Dawn Lobkovich at [email protected] in the Risk Management Department within one business day. The email subject line should read:

First Report of Injury and illness or simply FROI. Risk Management will need a copy

of the signed First Report of Injury or Illness form with the employee’s signature

for the Risk Management file, which can be sent via courier or fax to (407) 320-

0411 or ext 50411.

5. Temporary Staffing Employees: Any person employed by a temporary staffing agency who has been assigned to work at a SCSB facility and who has suffered an injury in the course of performing his or her employment duties will need to be referred to the temporary staffing agency’s workers’ compensation contact (see page 14). (Give the injured temporary worker a copy of page 14 and document in writing that the temporary worker has been given the reporting information). Any person who is not employed by SCSB but who is injured while at an SCSB facility should be referred to that person’s employer’s workers compensation contact.


HOWEVER, IT IS IMPORTANT THAT A SCHOOL ADMINISTRATOR

INVESTIGATE ANY CLAIMED INJURIES AND COMPLETES AN INJURY

REPORT FORM FOR THE INCIDENT WHETHER OR NOT TREATMENT IS

REQUESTED (SCSB Form No.447). 6. Medical Treatment Claims: Once the employee has requested to seek medical treatment, in addition to completing the First Report of Injury or Illness form, the following forms should be filled out. The forms listed below are not to be given to employees hired through a temporary employment agency, see page 14:

Notification Form (Page 8)

Medical Report for Treatment Form (Page 10) PMOA Workers’ Compensation Prescription Information Form (Page 11)

The following forms are to be given to the regular employees to take along to the doctor

for treatment. Again, the forms listed below are not to be given to employees hired through a temporary employment agency, see page 14:

Medical Report for Treatment Form (Page 10) PMOA Workers’ Compensation Prescription Information Form (Page 11)

(Please note: that the PMOA Workers’ Compensation Prescription Information

included is temporary. A prescription card will be mailed to the injured

employee’s home address.) The following forms are to be given to the employee for their information:

Medical Provider List (Page 9)

The workers’ compensation contact should then direct the employee to the most convenient Centra Care or Care Spot Medical Facility, and the workers’ compensation contact should keep a copy of all forms given to the injured employee for the employee’s workers’ compensation file. 7. Report Only Claims: The workers’ compensation contacts are to give the injured employee the following documents only if they are not seeking medical attention, in addition to the First Report of Injury or Illness form:

Notification Form (Page 8) Please note that if at a later date the injured employee wants to seek medical treatment, update the First Report of Injury or Illness form to show that the injured employee wishes to seek medical treatment and refer back to steps #4 and #6. When there is a delay, the adjuster should make the determination on referral for care unless it is a true emergency (if care is delayed, it shouldn’t be an emergency).


8. The workers’ compensation contact does not need to obtain a signed Choice Form (Page 13), until the employee is taken off duty by a doctor. Then if the employee wants to charge the difference between workers’ compensation pay and his/her full salary, the employee may choose to use part of his/her sick leave or vacation leave. The workers’ compensation contact is to send the original signed Choice Form (Page 13) to the cost center’s payroll specialist in the Human Resources Department and place a copy in the injured employee’s file at the cost center. Do not send a copy of this form to Risk Management. 9. The first ten (10) days of an injured employee’s absence from work due to

doctor’s orders (must be verified by a signed notice from the authorized workers’

compensation doctor) is to be reported as In-Line-of-Duty-Leave (payroll code: INDLV). Workers’ compensation will take effect for payment of wage benefits for the employee starting on the 11th day. The 11th day, and thereafter, should be reported

under workers’ compensation payroll code: WKCOMP. Under all circumstances, when an injured worker has been written out of work by the doctor, the Risk Management Department must be notified immediately.

If the employee is not out for the full ten (10) days, the unused days may be

used if the employee requires additional time off (due to doctor’s written orders) for additional treatment, etc. The maximum that will be paid is ten (10) days per year. Please note that only unused days relating to a specific injury will be carried forward to subsequent years. The workers’ compensation contacts are to report all time missed by the injured employee to Risk Management Department on a weekly basis via email.

10. The workers’ compensation contacts are to report any change in status, such as, if the injured employee is placed on light duty, modified duty, etc., to Florida School Boards Insurance Trust (FSBIT) via fax, e-mail or telephone contact. The Risk Management Department must be notified as well. 11. Please call Florida School Boards Insurance Trust (FSBIT), if you have any workers’ compensation questions. The School Board has contracted with Florida School Boards Insurance Trust to process all workers’ compensation claims. Please advise employees to call FSBIT with any questions. Employees who call Risk Management will be redirected to Florida School Boards Insurance Trust.


FIRST REPORT OF INJURY OR ILLNESS

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953

RECEIVED BY

CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE

PLEASE PRINT OR TYPE EMPLOYEE INFORMATION NAME (First, Middle, Last)

SOCIAL SECURITY NUMBER

- -

DATE OF ACCIDENT (Month-Day-Year)

TIME OF ACCIDENT

AM PM HOME ADDRESS

,

EMPLOYEE’S DESCRIPTION OF ACCIDENT (include Cause of Injury)

TELEPHONE Area Code Number

( ) - OCCUPATION

INJURY/ILLNESS THAT OCCURRED

PART OF BODY AFFECTED

DATE OF BIRTH

SEX

M F EMPLOYER INFORMATION

EMPLOYER/COMPANY

Seminole County School Board 400 East Lake Mary Boulevard Sanford, FL 32773-7127

FEDERAL I.D. NUMBER (FEIN)

596000855 DATE FIRST REPORTED (Month-Day-Year)

NATURE OF BUSINESS

Municipality

POLICY/MEMBER NUMBER

Self-Insured TELEPHONE Area Code Number

(407) 320-0242 or (407) 320-0208 DATE EMPLOYED

PAID FOR DATE OF INJURY

YES NO

EMPLOYER’S LOCATION ADDRESS (if different)

, Location #:

LAST DAY EMPLOYEE WORKED

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS’ COMP? YES LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS’ COMP?

RETURNED TO WORK? YES NO IF YES, GIVE DATE

PLACE OF ACCIDENT (Street, City, State, Zip)

,

COUNTY:

DATE OF DEATH (If applicable)

RATE OF PAY

PER

Number of hours per day

Number of hours per week

Number of days per week

HR WK DAY MO

AGREE WITH DESCRIPTION OF ACCIDENT?

YES NO

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section

440.105(7), F.S.

I have reviewed, understand and acknowledge the above statement.

__________________________________________________________ _____________________________________

EMPLOYEE SIGNATURE (If available to sign) DATE

______________________________________________________________ ________________________________

EMPLOYER SIGNATURE/ Phone Number DATE

NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL

CLAIMS-HANDLING ENTITY INFORMATION

1(a) Denied Case – DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3)

1(b) Indemnity Only Denied Case – DWC-12, Notice Of Denial Attached Employee’s 8th Day Of Disability

Entity’s Knowledge of 8th Day of Disability

3. Lost Time Case – 1st day of disability Full Salary in lieu of comp? YES Full Salary End Date

Date First Payment Mailed AWW Comp Rate

T.T. T.T.- 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment Interest Amount Paid in 1st Payment

REMARKS:

INSURER NAME CLAIMS HANDLING ENTITY NAME, ADDRESS & TELEPHONE

Florida School Boards Insurance Trust

P. O. Box 10709

Tallahassee, FL 32302-2709

850-414-0021

INSURER CODE #

9432

EMPLOYEE’S CLASS CODE

EMPLOYER’S NAICS CODE

SERVICE CO/ TPA CODE #

6214

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (03/2009) Rule 69L-3.025, F.A.C.


DWC-1 Purpose and Use Statement

The collection of the social security number on this form is specifically authorized by Section 440.185(2), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.

(Added 05/2011)


NOTIFICATION FORM

FOR SEMINOLE COUNTY SCHOOL BOARD

PRINT EMPLOYEE’S NAME: ________________________________________

DATE OF INJURY:

This is to advise you that it is your responsibility to notify your supervisor and the

person who handles workers’ compensation claims at your school/division of

your duty status and/or duty limitations. This notification should normally be the

same day as your doctor/hospital visit. If this is not possible, then notification

should be made to the above mentioned persons on the next regular duty day.

When you return to duty, you are to turn in the physician’s duty slip to your

workers’ compensation processor. Make sure you have a duty slip for each visit

with the physician. It is imperative that your supervisor know what, if any, duty

limitations the physician has prescribed. Further, be advised that once released

to return to duty by your physician you are to report as directed. FAILURE TO

REPORT FOR DUTY OR PROPERLY REPORT YOUR ABSENCE PURSUANT TO

BOARD POLICY AND/OR NEGOTIATED CONTRACT LANGUAGE WILL RESULT IN

YOU BEING ABSENT WITHOUT APPROVED LEAVE AND MAY BE GROUNDS FOR

IMMEDIATE DISMISSAL.

I have read and received a copy of this statement and fully understand my

responsibilities in this matter.

EMPLOYEE’S SIGNATURE:_________________________________________

DATE:_____________________________________


MEDICAL PRIMARY PROVIDER LIST


As your employer, we want to make sure that you get the proper medical treatment as soon as possible so that you can recover completely and continue to earn 100% of your income. Therefore, there are designated local medical providers to render the necessary medical treatment for our employees.

SEMINOLE COUNTY SCHOOL BOARD DESIGNATED MEDICAL PROVIDERS: *Employees may visit any Solantic or Centra Care center in Seminole or Orange County, or any center on this list. Visit www.carespot.com or www.centracare.org for a listing of locations.

CARE SPOT EXRESS

HEALTHCARE

(All Central Florida Locations)

HOSPITALS *Use only after 11 PM or if Injured

Employees are Transported in

Ambulance - Patients seen based

on Medical Priority

CENTRA CARE

(All Central Florida Locations)

LAKE MARY 136 Parliament Loop, Ste.102

Lake Mary, Florida 32746 (407) 333-0160

CENTRAL FLORIDA

REGIONAL HOSPITAL 1401 West Seminole Boulevard

Sanford, Fl 32771 Phone: (407) 321-4500

SANFORD 4451 West 1st Street

(State Road 46) Sanford, FL 32771

Phone: (407) 330-3412 WINTER SPRINGS

5355 Red Bug Lake Road Winter Springs, Florida 32708

(321) 304-3300

SOUTH SEMINOLE HOSPITAL 555 West State Road 434

Longwood, FL 32750 Phone: (407) 767-1200

LONGWOOD 855 South U.S. Highway 17-92

Longwood, FL 32750 Phone: (407) 699-8400

APOPKA 3840 East S.R. 436, Ste 1000

Apopka, Florida 32703 (407) 478-3202

ORLANDO REGIONAL

HEATHCARE SYSTEM 1414 Kuhl Avenue Orlando, FL 32806

Phone: (407) 841-5111

OVIEDO 8010 Red Bug Lake Road

Oviedo, FL 32756 Phone: (407) 977-3677

ORLANDO

(Fashion Square) 4301 East Colonial Drive Orlando, Florida 32803

(321) 319-0212

FLORIDA HOSPITAL

EAST ORLANDO 7727 Lake Underhill Orlando, FL 32822

Phone: (407) 303-8110

ALTAMONTE SPRINGS 440 West State Road 436

Altamonte Springs, FL 32714 (407) 788-2000

ORLANDO 2323 South Orange Avenue

Orlando, Florida 32806 (407) 418-9999

WINTER PARK

MEMORIAL HOSPITAL 200 N. Lakemont Ave Winter Park, FL 32792 Phone: (407) 646-7000

WATERFORD LAKES 250 North Alafaya Trail Suite 135

Orlando, Florida 32825 (407) 381-4810

Any other Florida Hosp

Affiliation

NOTE: If you have questions about your workers’ compensation benefits, contact Karey Edwards at (850) 414-0818 x315, Krista Casey (850) 414-0818 x318, or Rhonda Brock, RN (Nurse Case Manager) at (850) 414-0818 x312. NOTE: In emergency situations you may immediately seek treatment from the nearest qualified facility or provider. All medical treatment must be precertified by contacting FSBIT at (850) 414-0892 x315 Monday through Friday from 7:30 AM until 5 PM. Emergency treatment must be precertified within 48 hours of the provision of care. You or your provider can initiate the precertification contact. Precertification appeals can be initiated at the same number.

http://www.carespot.com/

http://www.centracare.org/


MEDICAL REPORT FOR TREATMENT FORM

FOR SEMINOLE COUNTY PUBLIC SCHOOLS WORKERS’

COMPENSATION

EMPLOYER/EMPLOYEE INFORMATION Workers’ Compensation Processor complete and provide to the injured worker prior to visit with approved medical provider. Injured Employee ________________________________ Position/Job ____________________________________ Describe Injury __________________________________ _______________________________________________ Date of Injury ____/____/____ Time _______AM/PM Work Location Name______________________________ Work Location # ____________Phone # ______________ Processor’s Signature ____________________________ Date _____________________

EMPLOYEE AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize the medical provider completing this to provide Seminole County School Board and/or their workers’ compensation representative(s) with all information pertaining to my work-related injury including my applicable medical history, physical condition and treatment provided to me.

__________________________________________ Employee’s Signature

__________________________________________ Date

NOTE TO TREATING PHYSICIAN AND EMPLOYEE

LIGHT DUTY, RESTRICTED OR MODIFIED DUTY. SCSB will make reasonable efforts to provide the employee with light, restricted or modified work in accordance with restrictions stated below, when the employee is released by the medical provider to return to light duty or modified duty prior to discharge at maximum medical improvement. Accommodations after discharge at maximum medical improvement will be provided in accordance with law.

If hospitalization is necessary, or if the employee is unable to return to normal or modified work within three days, please notify the employee’s supervisor at the above number.

CALL FSBIT FOR PRECERTIFICATION AT (850) 414-0818 x315 or x312 for all non-emergency hospitalization or surgery, physical therapy or chiropractic treatment.

TO REFER TO ANOTHER PROVIDER CALL: the Nurse Case Manager, Rhonda Brock, RN at 850-414-0818 x 312

MEDICAL INFORMATION/REPORT (To Be Completed By Medical Provider) Diagnosis/Treatment_____________________________________ Medications _______________________________ Patient is released to Normal Duties Restricted Duties As Of _____/______/______ Time ________ AM/PM IF PATIENT IS RELEASED TO RESTRICTED/MODIFIED DUTIES, THE FOLLOWING RESTRICTIONS SHOULD APPLY FOR _______ # DAYS, FOLLOWING WHICH TIME NORMAL DUTIES CAN BE EXPECTED. (CHECK ALL THAT APPLY.)

1. No lifting/carrying over 5 lbs. 10 lbs. 25 lbs. 35 lbs. 50 lbs. 2. No squatting/kneeling 3. No bending/stooping 4. No standing/walking 5. No driving 6. Must keep wound clean/dry 7. Needs to sit/stand as needed 8. May not work with left right hand/arm foot/leg for ______ day(s)

9. May work part-time only for ___ __hours/days for____ day(s) ____ week(s) Other (Specify) _________ 10. Completely disabled from working until ____/____/____

Follow-up appointment is needed with___________________________on ______/______/______ Physician’s Name_______________________________________ Telephone Number_______________________ Physician’s Signature___________________________________ Date__________________________________

PLEASE FAX THIS FORM TO THE FSBIT NURSE AT (850) 414-0893 IMMEDIATELY UPON EXAMINING PATIENT.


Florida School Board Insurance Trust

Workers’ Compensation Prescription Information

Please fill out employee information below and provide employee with this document to take to any

pharmacy with prescriptions.


PARTICIPATING PHARMACIES


WORKERS’ COMPENSATION

**An injured employee is entitled to use any pharmacy or pharmacist dispensing and

filling prescriptions for medicines of his/her choice. Below are a few known

companies that use the PMOA Prescripton Program. If your preferred pharmacy is

not listed, please view our website for a more complete list of participating

pharmacies.

1. WALGREEN DRUGS

2. WAL-MART

3. WINN-DIXIE

4. PUBLIX

5. TARGET

6. RITE AID

7. MEDICINE SHOPPE

8. CVS


CHOICE FORM


WORKERS’ COMPENSATION OPTION FOR PAYROLL

School Board policy provides up to a maximum of ten (10) days per fiscal year of ‘IN LINE OF DUTY LEAVE” for employees injured in the performance of official duties. If after using the ten (10) ‘IN LINE OF DUTY LEAVE” days you are unable to return to work AND have qualified to receive workers’ compensation benefits, you will be paid two-thirds (0.6667) of your average weekly wage up to the maximum compensation rate established by law, from our workers’ compensation provider, FSBIT-Florida School Boards Insurance Trust. You may elect to use your accrued sick leave or vacation leave to cover one-third (0.3333) of each day of workers’ compensation absence which is not paid by FSBIT.

If you elect to use accrued sick leave or vacation leave, one-third (0.3333) of a day will be charged to your accrued leave balance for each day of workers’ compensation absence. Your bi-weekly gross pay will reflect a reduction of two-thirds of a day’s pay for each day of workers’ compensation absence which will be reimbursed to you by FSBIT (Florida School Boards Insurance Trust). If you elect this option, your School Board pay will be received on your regularly scheduled pay dates.

Please indicate below the option you wish to take. This form must be completed and returned to the PAYROLL SPECIALIST for your school.

*NOTE: A one week lag will occur in reporting workers’ compensation absentee data therefore, a final adjustment of pay (+ or -) will be made to the employee’s first regular paycheck following his/her return to duty.

OPTION 1:

I authorize the School Board to deduct from my accrued sick leave balance, one-third (.3333) of a day for each day of workers’ compensation absence.*

OPTION 2:

I authorize the School Board to deduct from my accrued vacation leave balance, one-third (.3333) of a day for each day of workers’ compensation absence.*

OPTION 3:

I authorize the School Board to use both sick and vacation leave to cover my workers’ compensation absence. Please indicate which type of leave should be used first.* Sick___________ Vacation _____________

OPTION 4:

I do not wish to use sick or vacation leave for any absence related to this injury.*

Employee Signature Date of Injury

Print Name Current Date Social Security Number School/Department


TEMPORARY STAFFING EMPLOYMENT AGENCIES

(for Workers working through Temporary Staffing Agencies or any other Non-SCSB Worker,

injured while providing services on SCSB Property)

**Please do not fill out the The First Notice of Illness or Injury Form (DFS-F2-DWC-1) for Temporary Staff Employees .

Temporary Staffing Employment Agencies Workers’ Compensation Contacts:

AUE (American United Employers) 777 East Altamonte Drive, Suite 102 Altamonte Springs, Florida 32701 Karen Morris/Terry Wiseman - Contact (321) 397-2555 x349 – Phone (321) 946-5643 – Karen Cell (407) 666-7381 – Terry Cell (407) 788-3384 - Fax

On Target Staffing 16 South Semoran Blvd., Orlando, Florida 32803 (407) 277-9299 – Judy Bonet (407) 277-1007 – Priscila Ramirez

Compass Home Health Care 452 Osceloa Street Altamonte Springs, Florida 32751 (888)611-0001- Valerie Jeune (305) 491-4308 – Bernadette Rodriguez

Sunrise Staffing 4699 North SR 7, Suite 5, Tamarac, Florida (800) 457-0971 – Jean Guillaume (800) 889-0418 – Guerline Majuste (800) 889-0418 - Fax

Fast Track Staffing 5166 East Colonial Drive, Orlando, Florida 32803 (352) 922-2040 x202 – Margaret Renaud (352) 622-2040 x 204 – Chrystal Ramsay

Top Talent 210 Bumby Avenue, Suite A, Orlando, Florida 32803 Frances Garcia - Contact (407) 896-2150 – Phone (407) 896-2151 – Fax

Manpower Hospitality 445 West SR 436, Suite 1013 Altamonte Springs, Florida 32701 Ray McArdle - Contact (407) 857-6161 – Phone (407) 697-6341 - Cell (407) 859-3760 – Fax

Tri-State Employment 160 Broadway, New York, NY 10038 Phyliss Bianco – Contact (212) 346-7960 – Phone (212) 964-7457 - Fax

Injured Worker: Please contact your Temporary Staffing Employment Agency immediately upon receipt of this form. The above is a list of some of the temporary staffing employment agencies that provide services to SCSB. If your company is not listed above, please contact your supervisor immediately to obtain the proper procedures for reporting an on the job injury. If you have any questions regarding your injury, please contact your employer, immediately. *By signing this form below, you are acknowledging that this form was given to you on the date indicated, and that you will contact your employer immediately.

Temporary Worker’s Signature Printed Name Social Security Number Date of Accident Temporary Worker’s Employer Current Date Signature of Person Verifying Receipt of Form Print Name and Title of Verifying Person


Here are just a couple Work Comp issues that keep coming up:

1. NEVER use a previously submitted First Report of Injury even if it is for the same employee. A new document must be used each time. When old forms are used, information does not get changed such as dates, social security numbers, employee positions, etc...

2. Please remember to fax or send via courier the SIGNED First Reports of Injury to Dawn Lobkovich ASAP. The original signed FROI stays at the cost center. Risk Management only get a copy. If the employee is unable to sign, please send it to Dawn upon their return.

3. Be sure to E-MAIL the ELECTRONIC version as well to Dawn as scanned

copies will not upload. The electronic version will not have a signature on

it.

4. FSBIT Adjusters: JoAnne McBrayer, handles last names A-G, (800)790-2118 Ext 314 and Krista Casey, handles last names H-Z, (800) 790-2118 Ext 318

FSBIT FAX: (850) 414-0893

5. Please remember to fax (5-0411) or send via courier any notes from the

doctor to Dawn Lobkovich as well as the assigned FSBIT adjuster.

6. All bug bites, bee stings etc MUST be pre-approved by FSBIT before sending any employee for treatment. Of course, if they are allergic and are having a life threatening emergency, respond as you would to any emergency.

7. If an injury is ESE related, please indicate that on the Occupation line. (Ex:

Teacher-ESE)

8. WC Weekly Report: Please submit a response EACH WEEK with SPECIFIC dates the employee is out even if they are out for an extended period of time. I will also need notification of the specific DAY they returned from WC. In-Line-

Of-Duty days are only used for days that a DOCTOR specifically puts an employee out of work. We do not key employees out for follow-up appointments with the doctor. The employee is expected to return to work after the appointment or report to work prior to an appointment if there is reasonable

amount of time to do so. We do not key in partial In-Line-Of-Duty days.

9. If an employee is put on light duty and the school cannot meet the light duty restrictions, an administrator is to contact David Apfelbaum immediately to discuss other options. His contact number is (407)320-0208.

10. It is mandatory that the Work Comp Posters are posted in all staff work

rooms, mailrooms and the cafeteria staff dining room. Please contact

Dawn if you need more. Both the English and Spanish version need to be

posted.

workers’ compensation instruction booklet

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