Workers Compensation Procedures For Naf Supervisors Emergency Kit (Page 5 of 21) in pdf

Workers Compensation Procedures For Naf Supervisors Emergency Kit Page 5

“IN A NUT SHELL”

Upon notification of an on the job injury or illness, supervisor will issue to the injured employee the

following: Form LS-555-Privacy Act of 1974 Notice; Employee Information Sheet, Form LS-1,

Request for Examination and/or Treatment (with Part A, items 1-13 completed); Form LS-201, Notice

of Employee’s Injury or Death; and AF Form 786, Patient’s Authorization for Release of Medical

Information. Refer the injured employee to the medical treatment facility of their choice. Do not give

more than one Form LS-1 to an employee or medical service provider for any single injury. If the claim in

questionable, check item 7b on LS-1.

For the initial assessment/treatment, employees may seek to use any medical treatment facility to

include the base clinic, or a doctor of their choice. Any subsequent medical treating physician will remain

the treating physician for the life of the injury. The injured employee has the option to seek medical

attention. If the employee refused medical attention, have the employee provide a written statement

indicating they refuse medical attention at this time (may be written on LS-1). This does not mean the

employee may not seek medical attention at a later date. Employee may use Form LS-204 for to seek

future medical attention related to the same on the job injury.

Contact the HRO and Squadron Safety Office to report an on the job injury.

Submit all ORIGINALS to HRO Form LS-1, Request for Examination and/or Treatment (after medical

treatment facility completes part B); Form LS-201, Notice of Employee’s Injury or Death; Form LS-202,

Employer’s First Report of Injury or Occupational Illness; AF Form 786, Patient’s Authorization for

Release of Medical Information; AETC Form 435 On or Off Duty Ground Mishap Report.

For each and every follow up treatments, provide employee with Form LS-204, Attending

Physician’s Supplementary Report.

All original forms, doctors’ notes, etc. are to be returned to the HRO.

Provide HRO with a copy of the time cards.

Maintain contact with HRO until employee returns to duty w/out restrictions.

Workers Compensation Procedures For Naf Supervisors Emergency Kit Page 5