What to Do If An Injury Occurs at Work UCOP Goleta For this month’s safety meeting we will discuss the UCOP procedures on what to do if an injury occurs at work and the requirements for completing an incident report. Prepared and Developed by Erin Choi, UCOP Student Intern

Injury at Work: Instructions on UCOP Webpage UCOP Human Resources: http://hrop.ucop.edu/ Employee – Injury at Work: www.ucop.edu/humres/workers_compensation/employee/injury.html Supervisor/Manager – Injury at Work: www.ucop.edu/humres/workers_compensation/supervisor/injury.html If you are injured at work, the procedures and the required steps can be found on the UCOP webpage. There are specific instructions depending if you are the injured employee or if you are the supervisor/manager of the injured employee.

What to Do If an Injury Occurs at Work (Employees) If injured at work: Report incident to your supervisor immediately Promptly obtain proper medical care If emergency care is needed: Go to nearest emergency room Report injury to your supervisor as soon as possible For follow up care, go to UCOP’s Occupational Health Center or your designated physician If you are an employee and you are injured at work: Immediately report the incident to your supervisor If medical care is needed either: - Go to one of UCOP’s designated occupational health centers; or - To your own primary care physician – BUT ONLY IF YOU HAVE FILLED OUT A PRE-DESIGNATION FORM PRIOR TO YOUR INJURY If the injury is such that emergency care is needed: Go to the nearest emergency room Report your injury to your supervisor as soon as possible If follow-up care is needed, go to one of the UCOP’s designated occupational health centers or your designated primary care physician if you have completed the pre-designation form UCOP HR will provide you an Employee Claim Form (DWC-1). THIS FORM MUST BE COMPLETED AND RETURNED TO HR IF YOU HAVE RECEIVED MEDICAL CARE

UC Designated Occupational Health Facilities - Goleta Webpage: http://www.busserv.ucsb.edu/workerscompensation/mtaf.htm Occupational Medicine Center - Sansum/Santa Barbara Medical Foundation Clinic (SSBMFC) 101 S. Patterson, Santa Barbara 805-898-3311 Hours: Monday – Friday 8AM to 6 PM Urgent Care/Hitchcock Branch - Sansum/Santa Barbara Medical Foundation Clinic (SSBMFC) 51 Hitchcock, Santa Barbara 805-563-6133 Hours: Saturday – Sunday 9AM to 6 PM USE ONLY WHEN PATTERSON OFFICE IS CLOSED Medical Treatment – UCOP Designated Occupational Health Facilities for Goleta: If you need to seek medical treatment, there are the UC Designated Occupational Health Facilities are listed above CONTACT UCOP HR TO GET AUTHORIZATION PRIOR TO SEEKING TREATMENT

UC Designated Emergency Medical Facilities - Goleta Goleta Valley Cottage Hospital 351 S. Patterson Ave., Santa Barbara 805-967-3411 Hours: Every Day, All Hours Santa Barbara Cottage Hospital Pueblo at Bath, Santa Barbara 805-682-7111 Hours: Every Day, All Hours UC Designated Emergency Medical Facilities – Goleta The UC Designated emergency Medical Facilities locations are listed on the slide above.

Medical Treatment - Employee’s Personal Care Physician Employee can designate personal care physician Must have completed pre-designation form http://www.ucop.edu/humres/workers_compensation/employee/pre_form.pdf Employee should discuss with personal care physician Physician must agree to treat employee in accordance with California Workers Compensation Laws Medical Treatment – Employee’s Personal Physician: Employees can designate their personal physician for medical treatment, but the employee must complete a pre-designation form prior to injury. You can get the form from your Department’s Personnel Staff or via the UCOP webpage at the link on the slide. Employee Should Discuss with Their Personal Care Physician Physician must also sign the Form and agree to treat employee in accordance with California Workers Compensation Laws

What To Do If an Injury Occurs at Work (Employees Continued) If the treating physician certifies you for disability - Provide your supervisor with medical certification of: Any and all disability leave dates; Any and all future changes in disability leave dates It is your responsibility to keep your supervisor informed If the treating physician certifies you for disability, provide your supervisor with medical certification of: Any and all disability leave dates; Any and all future changes in disability leave dates It is your responsibility to keep your supervisor informed: It is important to keep your supervisor informed of leave dates. Your supervisor will need copies of your treating physician's certificates stating the dates of your medical disability. Your supervisor should also be informed of all future changes in those dates. Failure to provide this information may delay your payments and/or affect your other insurance coverage.

Injury at Work Supervisors – Three Immediate Actions Arrange medical care for the employee If employee has signed the pre-designated physician form on file; the employee can go to their physician Or refer employee to one of the UCOP Occupational Health Centers and contact HR Benefits Office Complete Incident Report – Section 2 Employee completes Section 1 Treating physician completes Section 3 Complete Employer’s Report of Occupational Injury/Illness Form (5020) http://www.ucop.edu/humres/workers_compensation/edb_prep/procedure_2.pdf If an employee is injured at work, there are three immediate actions which the supervisor must do: 1. Arrange for medical care for the employee: If employee has a signed pre-designated physician form on file; they can go to their own physician; or Refer the employee to the UCOP occupational health center and contact HR Benefits Office 2. Complete Section 2 of the incident report and give a copy to the employee to complete Section 1 3. Complete the Employer’s Report of Occupational Injury/Illness, the Form 5020 within 1 working day By taking these actions, the supervisor will: - Satisfy California State requirements - Minimize the severity of the employee’s injury; and - Prevent future injuries by maintaining a safe work environment.

UCOP Incident Reports Approximately 45 Incident Reports submitted every year Why complete an Incident Report? Documents the incident Differentiate first aid/minor injury incidents from workers compensation-type injuries Helps to significantly reduce UC’s workers compensation costs Human Resources & Department Safety Officer opportunity to review/investigate all incidents Number of Incident Reports: UCOP receives an average of 45 incident reports every year. Why Complete An Incident Report? - It is important for employees and supervisors to complete the incident report because the incident report would document the incident for future reference. - Allows UCOP Human Resources staff to review and differentiate first aid/minor type injuries versus injuries which should formally be classified as a potential workers compensation claim - This significantly reduces UC’s Workers Compensation costs - Provides Human Resources and the UCOP Department Safety Officers the opportunity to review and investigate all incidents. This will result in possible corrective action to prevent future incidents and therefore prevent a similar event from occurring in the future.

University of California INCIDENT REPORT Section #1 EMPLOYEE INFORMATION: Employee Completes This Section Campus: ______________________________________ Last four digits of social security number: _______________ Name PRINT: _______________________________________________________________Sex _ Male _ Female Home Address: __________________________________ City: __________________________Zip: ______________ Home Phone: ____________________________________ Work Phone:_____________________________________ Department: ______________________________ Job Title: _______________________________________________ Work Hours: ____________________________ Hours Worked per Week: ____________________________________ Employment Type _ full-time _ part-time _ regular _ temporary _ seasonal _student _ volunteer _ appointment Do you have other employment? _ yes _ no If so, where ___________________________________________________ INCIDENT INFORMATION Date of Incident _____________________ Time of Incident: ________________________ Address/Bldg, name & room # of incident: ____________________________________________________________ Zip Code __________________________ State all parts of body and type of injuries involve (e.g. bruised right elbow) ______________________________________________________________________________________________ Describe how incident occurred: _______________________________________________________________________________________________ Was incident reported? _ yes _ no If “yes” to whom? _____________________________________________________ Date reported: ________________________________ Were there witnesses? _ yes _ no _ unknown Name of Witness #1 (First and Last): __________________________________________________________________ Witness #1 Phone Number: _________________________________________________________________________ Name of Witness #2 (First and Last): __________________________________________________________________ Witness #2 Phone Number: _________________________________________________________________________ Is this a new injury? _yes _no If “yes” indicate date, If “no”, please indicate date of original injury INITIAL MEDICAL TREATMENT Was treatment received for this injury? _ No medical treatment- reporting only _ Declined treatment at this time _ Treatment was/will be provided Treatment was provided by: _ Self _ Occupational Health _ Emergency Room _ Other (please specify below) If treatment was provided, name and location of medical provider. Name: ____________________________________________ Address________________________________________ Phone: _________________________________________ I, the injured employee, herein certify the information above is true and to best of my knowledge Date: _______________________ Signature of Employee:____________________________________________________ Section 1 of the Incident Report Completed by the employee Section 1 of the Incident Report Form – Section to be completed by the employee.

Incident Report Form Section #2 Non-emergency situation: Supervisor completes Section 2 first; then Incident Report given to employee to complete Section 1 Incident Reports Handed/mailed to employee within 1 day of knowledge of on-the-job injury/illness If mailed – Use proof of service mail delivery form Section #2 SUPERVISOR COMPLETES THS SECTION: Supervisor Name: ___________ ___email address_____________ Work Phone: ___________________________________ Describe how the employee was injured. _______________________ ______________________________________________________________________________________________________________ _______________________________________________________ Did employee lose time from work? _yes_ no _unknown If ‘yes’ First day of lost time Was the Employee paid for the full date of injury? _ yes _ no Date Employee returned to Work._________________________ Was there equipment involved? _yes _ no If answered “yes” what was the equipment What action will be taken to prevent recurrence? ________________ Other Comments:_________________________________________ Date: ___________Signature:___________ Title:________________ Section 2 of the Incident Report Form. The supervisor should complete Section 2 first. The supervisor should then give the incident report form to the employee to complete Section 1. The Incident Report should be handed or mailed to the employee within one working day of knowledge of an on-the-job illness or injury. If the Incident Report form must be mailed to the employee it should be sent with a Proof of Service – Mail Delivery form.

Incident Report Form Section #3 Medical care provider Completes Section 3 of the Incident Report (If medical care is required) Section #3 MEDICAL PROVIDER COMPLETES THIS SECTION: ____________________________________________________________________________________ Medical Provider - What treatment was provided for this injury (check one) _ First Aid _ Medical Treatment Return To Work: Can Return immediately _yes _ no If no, date employee can return to work __________________________ _Full duty _ Restricted work Employee can return to work with these specific restrictions: ________________________________ Estimated period of absence: _______________ to_________________ Next appointment:___________ Date: ______________ Signature: _______________________________ Title: ____________________ Note: If, initially, first aid is rendered but at a later date treatment beyond first aid is required, please contact the Workers’ Compensation Department immediately and initiate the filing of a workers’ compensation claim. Seeking first aid treatment and completion of this report does not waive the employee’s right to file a workers’ compensation claim and seek benefits in accordance with statutory workers’ compensation laws. A physician who treats an injured employee is required to file a 5021 (“Doctor’s First Report of Injury”) with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work. Sections 3 of the Incident Report Form. If medical care is to be provided, the employee should bring the incident report form to the Medical Provider to complete Section 3.

Completed Incident Report Placed in employee’s workers compensation file Copy to UCOP Benefits Office: Hand delivered; or Fax (510)217-6062 Copy to Department Safety Officer: Investigation and recommend corrective measures Prevent similar incidents in the future Completed Incident Report After the Incident Report is completed, the supervisor should place a copy in the employee’s Workers Compensation file. A copy must be either hand delivered or faxed to the UCOP Benefits Office at 510-217-6062 Provide a copy of the incident report to your Department Safety Officer. The Department Safety Officer would then review and investigate the incident. This allows the Department Safety Officer to recommend corrective measures to prevent similar incidents from occurring in the future.

Employee Loses Time from Work (Supervisors) Contact Employee Dept. Benefits (EDB) Preparer or Department Personnel Assistant (DPA) for: Family Medical Leave Act (FMLA) Procedures and Eligibility Criteria Notify UCOP Return to Work/Vocational Rehabilitation Program. Reduce Lost Workdays: Provide medically appropriate modified work during the transitional stages of your employee’s medical recovery Call Roger Howland at (510) 987-0893 for: Assistance/consultation in designing Transitional/Modified work The day employee returns to work: Notify UCOP HR Benefits Office to prevent overpayment of disability benefits. For Supervisors – If an Employee Loses time from Work: Contact your Employee Departmental Benefits (EDB) Preparer/Departmental Personnel Assistant (DPA) for Family Medical Leave Act Procedures and Eligibility criteria Attempt to provide return to work or vocational rehabilitation - Reduce Lost Workdays by providing medically appropriate modified work during the transitional stages of your employee’s medical recovery. - Call Roger Howland at (510) 987-0893 for assistance and consultation in designing Transitional/Modified work. - The day your employee returns to work, notify UCOP HR Benefits Office to prevent overpayment of disability benefits. By taking these actions, the supervisor will: - Avoid legal fines and penalties being assessed against their departments. - Assure that their injured employee is getting compensation in a timely manner. - Minimize financial loss to the employee, the department, and the University as a whole

Injuries Call 9-911 (Emergency) Call UCOP Benefit Services as soon as possible to report the serious injury: (510) 987-0123 – Customer Service Line (510) 987-0819 – Anne Buckland (510) 987-0816 – Leslie Lyons (510) 987-0893 – Roger Howland Remove the equipment from service (If applicable) Tag the equipment for identification (If applicable) Contact Roger Howland at (510) 987-0893 to initiate an inspection For additional assistance – Contact UCOP Benefit Services Office In the event of emergency situations: Call 9-911 Call the UCOP Benefit Services Office ASAP to report the serious injury – The contact phone numbers are listed on the slide. If there is equipment involved in the injury, remove the equipment from service and tag the equipment for identification. It is important not to dispose or throw away the equipment in question. Contact Roger Howland, the Vocational Rehabilitation Specialist, to initiate an inspection. If you need additional assistance, call the UCOP Benefit Services Office