1. Workers’ Compensation May 2015 1

2. Management Training Class Workers’ Comp Overview for Managers Quarterly at SMUCLA and RRUMC June 16 RRUMC Covers processes and procedures related to Workers’ Compensation Reviews Disability Management and the Interactive Process 2

3. Who is eligible? Career, casual, Per Diem employees are covered from the first date of employment Vanpool injuries Non-UCLA employees are covered by their respective employers, e.g. Traveler’s, Registry, other temporary workers Volunteers 3

4. Initial Employee Contact Was this injury work related? If the employee believes it was work-related or is unsure, provide Workers’ Compensation forms and direct the employee to seek immediate medical treatment at either Occupational Health Facility or the UCLA Emergency Department Employee should tell the UCLA Emergency Department that they are a UCLAMC employee and that they are being treated for a work-related injury Follow all procedures for a leave of absence 4

5. Medical Treatment Where to send the employee for treatment? Employee should be seen by Occupational Health Facility or the UCLA Emergency Department for the first 30 days IF EMPLOYEE WAS SEEN AT THE EMERGENCY ROOM, direct employee to follow-up at UCLA Occupational Health. Medical Control: UC directs the employee’s medical care for an initial 30 days. UCLAMC’s designated providers are Occupational Health Facility (OHF), RRUMC Emergency Medicine, and SMUCLA Nethercutt Emergency Medicine Exception: Employee pre-designates personal Medical Doctor in writing prior to the injury. Contact WC HR for more information. 5

6. New Pharmacy Network The University of California (UC) has partnered with Helios to establish a Pharmacy Benefit Network (PBN) for workers’ compensation illness and injury related medications as part of the overall pharmacy program. Injured workers within the PBN will only be able to fill prescriptions from a pharmacy within the network after 4/1/2015. Posters should be posted next to the state mandated WC posters. Pamphlets will be given to all new hires with other state- mandated WC pamphlet 6

7. Cal-OSHA FOR SERIOUS INJURIES, page UCLA Health Safety at pager #90248 within EIGHT hours or call the Campus 24-hour call-in phone number EH&S Hotline: 310-825-9797 Serious injury includes: Amputation Concussion Injury resulting in serious degree of permanent disfigurement such as crushing injury or severe burn In-patient hospitalization >24 hours for other than medical observation OSHA requires notice within 8 hours of Serious Injury 7

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9. When an Employee is injured on the job... Provide the employee with: 1.A completed Workers’ Compensation Claim Form (DWC-1) and Notice of Potential Eligibility This form must be provided within 1 working day of notice that an injury or illness has occurred as mandated by California state law. (Exception: First Aid incidents) 2. A completed UCLA Incident Report and Referral for Medical Treatment 3. Workers’ Compensation Information Sheet 9

10. 10 Paperwork 1.Please review and complete all lines. Sign where appropriate. Supervisor should sign all forms where indicated 2.Department keeps one copy for department records. If notification was by phone, send the form to employee via Certified Mail 3.Immediately: 1. FAX a copy to the WC FAX line Health System HR 310 794 3337 or 2. EMAIL to hrworkerscomp@mednet.ucla.edu or 3. CALL 877-6UC-RPRT (877-682-7778) with the information on the form (see Step #5)

11. 11 Paperwork 4.Employee keeps one copy of completed form 5.Send all other copies of the form immediately to Health System HR for distribution 6.Notify Health System HR Workers’ Comp x40500 if employee has been taken off work. Follow all procedures for a leave of absence

12. Important Information Employees should be paid for the time at OHF and/or the EMC (to complete the work shift.) Charge hours to Home Cost Center Employees must use SL for any time at off-site (non-OHF or EMC) appointments, and for time taken for therapy, diagnostic appts Charge hours to Home Cost Center Employee may return to temporary work on a modified work schedule or modified duties at any time. Charge actual Modified duty hours worked as ‘Modified Duty Workers’ Comp’ and to the Return to Work Cost Center. 12

13. Disability Management Mark Briskie UCLA Health System Human Resources (310) 794-0525 Legal Responsibilities Workers’ Compensation Family Medical Leave 13

14. Contacts for Return to Work Program Contact UCLA Health HR Workers’ Compensation/ Return to Work coordinators to confirm employee meets eligibility criteria UCLA Health Human Resources WC 310 794 0500 Mark Briskiembriskie@mednet.ucla.edu310 794 0525 Cynthia Vazquezcvazquez@mednet.ucla.edu310 794 0522 Ingrid Garciaigarcia@mednet.ucla.edu310 794 3036 Return to Work Coordinators Mark Briskie mbriskie@mednet.ucla.edu310 794 0525 Suzanne Bleibtreusbleibtreu@mednet.ucla.edu 14

15. Injury Prevention resources UCLA Health Safety SAFETY INSPECTIONS/TRAINING ERGONOMIC EVAL ACCIDENT INVESTIGATIONS Jennifer Mempinjmempin@mednet.ucla.edu 310-267-9886 phone310 267 9887 fax PAGER 99828 SAFE PATIENT-HANDLING COORDINATOR Larona Taylor lataylor@mednet.ucla.edu 310-267-9897 phone310 267 9890 fax PAGER 91136 15

16. Injury Prevention resources Ergonomic Evaluation Request Form Bruin Ergo - UCLA UCLA Health Online Ergonomics Program (Cardinus) User ID = Employee ID Number (link on HR website) To request onsite eval: UCLA Health Support Services Center Bruin Break Jeri Simpson310 794 0500 jasimpson@mednet.ucla.edu 16

17. Directory SEDGWICK CMS P.O. Box 14533 Lexington KY 40512-4533 Mail code 691448 Phone 310 253 7500 Fax310 253 7569 CAMPUS PAYROLL UCLA Wilshire Center, Suite 620 MC 141648 Phone310 794 8706 Fax310 794 8751 UCLA HEALTHCARE PAYROLL UCLA Wilshire Center, Suite 1700 MC 167646 Phone 310 794 0127 Fax310 794 8049 17 OCCUPATIONAL HEALTH FACILITY (OHF) 67-120 Center for Health Sciences Monday through Friday 7:00 a.m. to 4:30 p.m. Mail Code 172524 Phone310 825 6771 Fax 310 206 4585 www.ohs.uclahealth.org EMERGENCY DEPARTMENT 757 Westwood Plaza (ER entrance Gayley Ave, N of Le Conte) Phone 310 267 8406 Open 24 hours a day SMH Nethercutt Emergency Room 1255 15 th Street, Santa Monica Phone424 259 8400

18. Policy Health System Policy HS 7318 Employee Work-Related Illness and/or Injury http://www.mednet.ucla.edu/Policies/pdf/enterprise/HS7318.pdf Health System Policy HS 7324 Employee Transitional Return to Work(TRTW) Policy http://www.mednet.ucla.edu/Policies/pdf/enterprise/HS7324.pdf 18

19. Other Required forms Required Workplace postings DWC 7 Notice to Employees – Injuries Caused By Work Workers’ Compensation Pharmacy Benefit Network HR Website http://hr.uclahealth.org New Employee Pamphlets Notice to Employees – Injuries Caused by Work Helios/Pharmacy Benefit Network Distributed at time of Hire by HR Rep Pre-designation of Physician form HR Website http://hr.uclahealth.org 19