I. SUPERVISORS:
1. Apply first aid if trained staff is available. Always notify the District Office immediately upon
any knowledge of an employee injury/illness regardless of the severity.
2. Direct injured employee for medical care if necessary;
a. Verify any designated physician on record for the employee by
contacting the following individual at the district office:
Name:________________________________________
Phone:________________________________________
3. Provide the employee with a Company Nurse On Call Wallet Card , or direct him/her to call
the toll free report phone number: 1-877-223-9311.
Note: Your employee will be greeted on the phone by a registered nurse who will answer
questions, walk them through self-care if appropriate, or connect them to medical care and initiate
the claim process.
4. Notify the District Office of the injury/illness. Contact the following individual at your district office:
Name:________________________________________
Phone:________________________________________
5. Advise the employee that they must return a Work Status Report prior to returning to work, and after each medical appointment. Contact the Tuolumne JPA Return-to-Work Coordinator 536-2035 if employee is taken completely off work or has any work restrictions.
II. DISTRICT OFFICE:
1. Upon Notice Of An Employee Injury/Illness:
a. The district office or supervisor will refer the employee to the Company Nurse On
Call phone line. This may be done by issuing a wallet card to the employee or referring
them directly to the system number: 1-877-223-9311
b. The Supervisor’s First Report will be completed by the nurse that receives the call and
this report will be sent to the following:
School District Contact
LWP Claims Examiner
JPA Return To Work Coordinator
Loss Control Specialist
NOTE:
® If the injury can be treated with self-care by the employee, a claim will not be
necessary and the Supervisor’s First Report will be used as an incident document.
If medical care is later necessary for the same injury, the employee will contact the nurse again, the nurse will refer the employee for medical care and a claim will be initiated.
® If the injury requires “first aid” treatment only, (see following JPA policy and OSHA
definition) set up a file to include the Company Nurse On Call reports and pay the
Medical provider within 60 days of receiving the billing. If an employee needs medical
care beyond first aid following initial care, they should be referred to the Company Nurse
On Call line.
2. When Medical Care Is Needed Initially:
a. If an employee needs medical care and cannot call the Company Nurse line – The
supervisor or district should call the Company Nurse line to start a claim.
b. The Employee’s Claim For Workers’ Compensation Benefits (DWC-1) The nurse will refer the employee to medical care, will partially complete the DWC-1 and email it to:
School District Contact – who prints out then sends the DWC-1 to the injured
employee for completion/signature and logs this action on the Log For Dispensing Employee’s Claim For Workers’ Compensation
c. The Employer’s Report of Occupational Injury or Illness (5020) will be partially completed by the nurse that receives the call and a website link will be emailed to:
School District Contact – who will go to the link, complete the 5020 and
“Submit” the completed form on the website. (There will be a submit
button to be clicked within the 5020 document on the website.) The School
District Contact will then print out the completed 5020 for filing.
Once the 5020 has been “submitted” by the district contact, copies of the
completed 5020 will automatically be emailed to the following:
JPA Return To Work Coordinator