Self Assessment Template

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WorkComp Self Assessment
________________________________________
To more clearly understand your current
situation, please complete the following
Scorecard.
Rate your level of confidence
form 1-10, with “1” being the lowest and
“10” being the highest.
1 2 3 4 5 6 7 8 9 10
1. How confident are you that your employees are getting
1 2 3 4 5 6 7 8 9 10
the right medical treatment when injured?
2. How confident are you that your injured employees
1 2 3 4 5 6 7 8 9 10
are returning to work and back to full productivity as
soon as possible?
3. How confident are you that you are hiring employees
1 2 3 4 5 6 7 8 9 10
that meet the physical demands of the Job?
4. How confident are you that you understand all the
1 2 3 4 5 6 7 8 9 10
costs the insurance company does not pay when an
employee gets injured?
5. How confident are you that your Supervisors are
1 2 3 4 5 6 7 8 9 10
aware of their role before and after an injury occurs?
6. How confident are you that your Experience
1 2 3 4 5 6 7 8 9 10
Modification Factor is free from errors?
7. How confident are you that you know how to manage
1 2 3 4 5 6 7 8 9 10
your Experience Modification Factor to the minimum?
8. How confident are you that you understand the risk
1 2 3 4 5 6 7 8 9 10
and dangers that an increasing Experience Modification
Factor poses to your business?
9. How confident are you that you are not being
1 2 3 4 5 6 7 8 9 10
overcharged on your premium audit?
10. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with federal and state safety requirements?
11. How confident are you that your safety programs
1 2 3 4 5 6 7 8 9 10
are reducing injuries?
12. How confident are you that you are in compliance
1 2 3 4 5 6 7 8 9 10
with Federal Worker’s Compensation Acts?
13. How confident are you that your company has
1 2 3 4 5 6 7 8 9 10
coordinated WC, Group Health, FMLA, COBRA and ADA?

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