Attachment to ASL 99-02


AIR RESOURCES BOARD
WORKERS' COMPENSATION GUIDE

LEGAL BASIS
FORMS AND INSTRUCTIONS
RESPONSIBILITIES

EMPLOYEE
SUPERVISOR
REVIEWING SUPERVISOR/MANAGER
SECTION, BRANCH, AND DIVISION CHIEFS
PERSONNEL OFFICE
LEGAL OFFICE
STATE COMPENSATION INSURANCE FUND

SUMMARY OF ACTIONS TO TAKE WHEN AN INJURY OCCURS
ROUTING INSTRUCTIONS

LEGAL BASIS

The Labor Code (LC) requires all employers, including the State of California, to provide Workers' Compensation benefits to its employees who are injured while working. State Administrative Manual Section 2580.2 requires all State agencies to establish, implement, and maintain written policies for an injury prevention program in accordance with LC Section 6401.7. In addition, agencies are also required to establish a reporting system for job-related injuries, illnesses, or death.

The State Compensation Insurance Fund (SCIF) is the adjusting agent/insurance carrier which manages workers' compensation claims and provides services to injured workers. A workers' compensation injury is any injury or illness that arises out of employment (AOE) or during the course of employment (COE). California law imposes strict reporting requirements on both the injured employee and the employer. The injured employee, his/her immediate supervisor, the second-line supervisor, and the Personnel Office share responsibility for timely and adequate reporting of the job-related injuries or illnesses. Without prompt, accurate reporting, the provision of benefits will be delayed and penalties and interest charges may be assessed against the department.

FORMS AND INSTRUCTIONS

ASD/PMB-207, FIRST-AID INJURY/ILLNESS REPORT

The ASD/PMB-207 has been developed to document and report any minor work-related injuries/illnesses such as scratches, cuts, splinters, bruises, and so forth which do not require professional medical treatment or result in lost time from work beyond the date of injury. It must be provided to the employee within one working day of knowledge of the minor injury/illness. Follow the completion and processing instructions on the bottom of the form. Do not issue a SCIF 3301 or fill out a SCIF 3067.

Note: If it later becomes necessary for the employee to seek professional medical treatment or lose time from work beyond the date of injury/illness due to this incident, then you must present the employee with the SCIF 3301 and fill out a SCIF 3067. Attach a copy of the ASD/PMB-207 to the SCIF 3067 before routing.

SCIF 3301, EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS (available through the ARB Workers' Compensation Coordinator)

The SCIF 3301 is for the employee to describe how, when, and where the injury/illness occurred. It was developed to protect the employer and employee when a work-related injury occurs. It is a record of the employee's intent to file a workers" compensation claim and acknowledges receipt of workers' compensation benefit information from the employer. The SCIF 3301 must be provided to the employee within one working day of knowledge of an injury/illness that has required professional medical treatment or caused the employee to lose time from work beyond the date of injury/illness.

ASD/PMB-208, ACKNOWLEDGMENT OF RECEIPT OF SCIF 3301

The ASD/PMB-208 has been developed as an acknowledgment that ARB has provided the injured/ill employee with the SCIF 3301 and must be given to the employee at the same time he/she is given the SCIF 3301. This form protects ARB in the event the employee claims he/she did not receive the SCIF 3301 and was not aware of his/her rights in regards to workers' compensation benefits.

13730, STATE EMPLOYEES' GUIDE TO WORKERS' COMPENSATION (available through the ARB Workers' Compensation Coordinator)

The 13730 is a pamphlet prepared by SCIF that explains the workers' compensation process. A copy of this pamphlet should be given to the employee after they have filled out a SCIF 3301.

SCIF 3067, EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS (available through the ARB Workers' Compensation Coordinator)

The SCIF 3067 is the form the employer must use to report a possible work-related injury/illness and must be completed and submitted within five working days of knowledge that an injury/illness has occurred. Completion of the SCIF 3067 is not an admission of liability, it is fulfilling a legal requirement. If there is any question or doubt that the injury or illness is work-related, a memorandum should be attached to the SCIF 3067 describing the facts as they are known including any supporting documentation and a request made for further investigation by SCIF. Some of the things to look for and report on in questionable claims are:

UNDER NO CIRCUMSTANCES IS THE EMPLOYEE TO COMPLETE AND SIGN THE SCIF 3067.

The following situations require the completion of a SCIF 3067:

*This applies in the event that a claim form is received from an attorney's office and this is the first notification that an injury/illness has occurred, or an additional injury/illness is reported that was not identified on the original SCIF 3067.


The supervisor must complete the SCIF 3067, front and back, as follows:

Front
Reverse

As indicated on the reverse side of the SCIF 3067, do not hold up submission of the form for completion of the reverse side.

Supervisor's review
- This section must be completed by the employee's immediate supervisor who must:
Manager's review
- The manager must review the immediate supervisor's remarks and indicate whether he/she concurs with the report.

Note: The Board is responsible for preserving all evidence related to the injury/illness (i.e., furniture, equipment). If evidence cannot be preserved, such as wet floors or loose tiles, arrangements should be made, if possible, to have the scene photographed.

Questions regarding the completion of the form or supporting documentation should be referred to the Workers' Compensation Claims Coordinator in the Personnel Office.

RESPONSIBILITIES

EMPLOYEE

If an employee is injured or becomes ill as a result of their job, he/she must report the injury to his/her supervisor as soon as possible. In cases of minor injuries, the employee should obtain first aid and return to work.

After receiving treatment for the injury, the employee must inform his/her supervisor of the physician's advice concerning the employee's ability to resume work responsibilities. All time off work related to the injury/illness must be reported on the time report, ASD-26. Although no time is charged against leave credits on the day of the injury, a notation must be made to show the date of injury on the time report. A statement from the attending physician is required each time the employee is seen regarding the work-related injury/illness and when the employee is allowed to return to work, with any work restrictions noted. All physician statements must be attached to the time report and forwarded to the Personnel Office following the pay period in which the injury occurred.

SUPERVISOR

The supervisor is responsible for carrying out State and departmental return-to-work and injury prevention policies. This responsibility includes assuring prompt medical treatment is obtained if any employee is injured or becomes ill due to his/her job duties. The supervisor must arrange for transportation and may either designate a representative or accompany the injured employee to a physician's office or hospital. If the employee has pre-designated a physician before the injury by completing SCIF 15306 and placing it in his/her Official Personnel File, the employee can go to that physician for treatment immediately after an injury. Otherwise, the department is responsible for arranging treatment. If the department does not refer the employee to a physician after being notified of the injury, the employee may then choose his/her own physician. It is important to inform the treating physician that the employee's injury is work-related. The supervisor must notify the Workers' Compensation Claims Coordinator in the Personnel Office immediately following a work-related injury.

The supervisor should maintain frequent contact with the injured employee and arrange for the employee to return to work as soon as it is medically feasible. Remember to request physician's verification that the employee is medically cleared to return to work, with any work restrictions noted. The supervisor is also responsible for providing information to the second-line supervisor/manager and the Personnel Office regarding the status of the injured employee.

REVIEWING SUPERVISOR/MANAGER

The reviewing supervisor/manager shall review the information provided on the SCIF 3067 for accuracy and completeness and in the appropriate area indicate whether he/she agrees or disagrees with the first-line supervisor's recommendation.

SECTION, BRANCH, AND DIVISION CHIEFS

Section, Branch, and Division Chiefs will review section injury reports, monitor safety issues and provide input for potential settlements.

PERSONNEL OFFICE

Whenever a work-related injury/illness occurs, the supervisor should contact the Workers' Compensation Claims Coordinator for assistance and to receive the appropriate forms.

Upon receipt of the completed forms the Workers' Compensation Claims Coordinator will review them for completeness, log the claim into the process, and mail the original copies to SCIF. An Employee's Responsibility Memo, the employee's copy of the SCIF 3301, the "State Employees' Guide to Workers' Compensation" pamphlet, the "Industrial Disability Leave Benefit Options" pamphlet, and the "How to Report Your Attendance" pamphlet are sent to the employee.

If the claim is accepted, the STD 618s, Benefit Option Selection Form is sent to the employee.

If the claim is denied, SCIF will mail the employee a denial notice stating the reasons for the denial and provide a copy to the Workers' Compensation Claims Coordinator.

The Workers' Compensation Claims Coordinator provides input to a claimant's work unit and to the injured employee about the various stages the claim goes through. The Workers' Compensation Claims Coordinator also acts as a liaison between the claimant and the SCIF Claims Representative and assists in providing the material necessary for the SCIF Claims Representative to make decisions regarding the claimant's absence due to the claim.

The Personnel Analyst will be informed of injuries with time lost and be given periodic updates. The Personnel Analyst will communicate with the Workers' Compensation Claims Coordinator any disciplinary issues that might affect the workers' compensation claim.

LEGAL OFFICE

The Workers' Compensation Claims Coordinator will contact ARB's Legal Office for guidance on complicated workers' compensation claims. Any settlement offers, Compromise and Release, and Stipulated Agreements will be sent to the Legal Office with a brief write up and recommendation by the Workers' Compensation Claims Coordinator, along with the case file for review and recommendations.

STATE COMPENSATION INSURANCE FUND

The State Compensation Insurance Fund reviews all claims and medical reports and will determine and approve benefit periods. They are also the State's representative when an appearance is required before the Workers' Compensation Appeals Board.

SCIF has fourteen (14) days from the date of the employer's knowledge of the injury to contact the employee and inform him/her of the status of the claim. SCIF must make a determination within ninety (90) days of the employer's knowledge of the injury or the claim is automatically accepted.

Upon completion of their investigation and acceptance of a claim, SCIF will notify the Workers' Compensation Claims Coordinator via a SCIF 3290, Notice of Benefits and Temporary Disability Verification of State employee. The SCIF 3290 will reflect the dates and/or hours SCIF has accepted and approved as disability and also authorizes the Workers' Compensation Claims Coordinator to request and release industrial disability leave benefits. The Personnel Office must have an approved 3290 before releasing any payments to the employee.

SUMMARY OF ACTIONS TO TAKE WHEN AN INJURY OCCURS

STEP
WHO
ACTION TO TAKE
TIME FRAME
1
Supervisor
First-Aid
Gives employee ASD/PMB-207 & routes as indicated below.

Professional medical treatment or time off work beyond the date of injury
Completes employer section of SCIF 3301 and gives to employee along with the State Employees' Guide to Workers' Compensation Pamphlet.
1 working day


1 working day
2
Supervisor
Has employee sign ASD/PMB-208 & detaches lower portion.
1 working day
3
Supervisor
Fills out SCIF 3067, attaches ASD/PMB-208 & routes as indicated below.
5 working days
4
Employee
Completes employee section of SCIF 3301 (if pursuing claim) & returns to supervisor.
5 working days
5
Supervisor
Gives employee "Temporary Receipt" copy of SCIF 3301.
Upon receipt
6
Supervisor
Enters date received in appropriate section of SCIF 3301, fills out SCIF 3067, & routes as indicated below.
Upon receipt

ROUTING INSTRUCTIONS

FORM

COPIES

ROUTE TO

ASD/PMB-207
Original

Copy
Workers' Compensation Analyst

Employee
SCIF 3067
Original

Copy
Workers' Compensation Analyst

Reporting Unit File
SCIF 3301
Original, Employers' copy, & Employee's copy

Employee's Temporary Receipt
Workers' Compensation Analyst


Employee
ASD/PMB-208
Original

Copy
Workers' Compensation Analyst

Reporting Unit File