Workers Compensation Procedures For Naf Supervisors Emergency Kit (Page 6 of 21) in pdf

Workers Compensation Procedures For Naf Supervisors Emergency Kit Page 6

INSTRUCTIONS FOR SUBMISSION OF WORKERS COMPENSATION FORMS

TIME FRAME (SUSPENSES)

FORM

COMPLETED BY

FORWARDED TO

LS-1, Request for Examination and/or Treatment

Supervisor completes

Employee takes to 1st Dr visit then

Only if deemed necessary –

Date of injury or soon after if it is an emergency

FRONT page

returns to HRO after Dr completes

or w/ Dr notes

Call HRO for Approval

Physician - BACK Page

LS-202, Employee's First Report of Injury or

Date of injury or soon after

Supervisor

HRO

Occupational Illness

Squadron Safety Officer

Date of injury or soon after

AETC FORM 435 Mishap Data Worksheet

Supervisor

Copy to HRO

AF Form 786, Patients Authorization for Release

Date of injury or soon after

Employee READS & SIGNS

HRO

of Medical Information

LS-555 U.S. Department of Labor Employment

Date of injury or soon after

Standards Administration Office of Workers'

Read ONLY

HRO

Compensation Programs

IF EMPLOYEE DECLINES MEDICAL ATTENTION AT TIME OF INJURY, HAVE THEM SIGN THE DECLINATION OF MEDICAL ATTENTION FORM.

LS-201, Notice of Employee's Injury or Death OR

Date of injury or soon after

written statement

EMPLOYEE ONLY

HRO

LS-201 IS NOT TO BE TYPED

If someone other than the employee completes the LS-201 and employee goes to the Dr, the claim will be denied by WC and employee will be responsible for the Dr visit.

We are dealing with the DOL and it's a crime for anyone other than the injured party to complete the LS-201. If employee is unable to complete the LS-201 form due to

not being able to read or write in English or is physically unable due to incapacitating emergency, the supervisor can write a statement on behalf of the employee on a

separate sheet of paper and write "written for (employee name) due to (give reason)" and sign (supervisor name and title).

FOR FOLLOW-UP ONLY

LS-204, Attending Physician's Supplementary

Physician

Within 24 hours of employee's return to work

Report of Accident

HRO

Form is for follow-up

appointments ONLY

FOR FOLLOW-UP APPT ONLY

LS-210, Employer's Supplementary Report of

Within 24 hours of employee's return to work