Workers’ Compensation

Employee Packet

WORKERS’ COMPENSATION GUIDELINES

Leave of Absence Information Employees that report a work-related injury, accident, or illness that requires medical attention, are required to bring the Texas Workers’ Compensation Work Status Report (DWC-73 Form) to the Workers’ Compensation Office at the Lyford CISD, Lincoln-Lee Adm. Annex, 8240 Simon Gomez Rd, Lyford, TX, before returning to work. Approval must be issued in writing to Supervisor stating conditions and restrictions, if any, on employee’s work. Any employee that is on time loss due to a work related injury will be concurrently placed on Family Medical Leave (FMLA). If qualified, FMLA is a job protection for up to 12 weeks of leave. The insurance payments are to be made at the Lyford CISD Insurance Department before the first (1st) of each month in order to keep the insurance in force. If the employee does not make insurance premium payments, the insurance will be canceled. Substitution of paid leave shall not be made to any employee who is receiving workers’ compensation benefits during a designated FMLA leave. 29 CFR 825.207 (d) (1), (2) This means that an employee receiving workers’ compensation benefits cannot receive state or local sick leave, extended or donated days while on Family Medical Leave. If an employee is absent less than eight (8) days, no workers’ compensation benefits will be received. Therefore, during those seven days, the employee is eligible for paid sick leave benefits. If no paid benefits are available or when sick leave has expired, the employee will be docked the daily or hourly rate, with the possible exception of assault leave. An employee who is physically assaulted during the performance of regular duties should inform their supervisor. Under certain circumstances, if an employee is out of work for an extended period of time and does not foresee a return to employment, he/she may extend insurance coverage for a maximum of 18 months from date of employment separation, without affecting Workers’ Comp benefits, under Federal Continuation Rights, Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Full explanation of continuation rights is covered in employee’s Group Benefit Plan book.

LIABILITY FOR COMPENSATION The Texas Department of Insurance (TDI) describes our liability for employee injury or illness without regard to fault or negligence if a Lyford CISD employee’s injury arises out of the course and scope of employment. BENEFITS TO INJURED EMPLOYEES Medical Benefits (TDI: Sections 4.61, 4.69, 8.01, and 8.42)

An injured employee is entitled to all reasonable and necessary medical benefits that promote recovery or enhance the ability to work. All medical benefits must be approved or recommended by your treating doctor from The Alliance network. An injured employee is also entitled to receive necessary prescription drugs as prescribed by the treating doctor. Lyford CISD employees may choose their own doctor from The Alliance network. If the employee wants to change doctors after the first choice, he/she can ONLY choose from The Alliance list of providers. A third choice requires approval from the adjuster. The district’s workers’ compensation office may be contacted by medical providers for authorization or verification of payment of medical benefits for a workers’ compensation injury. This usually occurs in an emergency situation for initial care. Under emergency situations the Workers’ Compensation Representative will verify that a work related injury has been reported but will not authorize or deny treatment. The responsibility of acceptance or denial regarding compensability lies with the carrier.

Prescription The Texas Association of School Boards and Progressive Medical, Inc. have joined together to provide injured parties with a “First Fill” medication card program. First Fill medication card enables injured parties to obtain the “initial prescription(s) needed upon injury with little to no out-of-pocket expense. If your claim is accepted, you will receive a Retail Drug Card in the mail. Present that card when filling subsequent related prescriptions.

Income Benefits

Texas Department of Insurance – Division of Workers’ Comp will replace a portion of your weekly income if you can not perform your regular duties due to a work-related injury or accident.

a) If you earn less than $8.50 an hour, you will receive 75% of your average weekly wage with certain restrictions.

b) If you earn more than $8.50 an hour, you will receive 70% of your average weekly wage with certain restrictions.

GUIAS DE COMPENSACION PARA EL TRABAJADOR

Información sobre Licencia para Ausentarse Empleados que reportan una lesión, accidente o enfermedad relacionada con el trabajo que requiere atención médica, se les requiere que traigan la forma Texas Workers’ Compensation Work Status Report (DWC-73), al Lyford CISD, Lincoln-Lee Adm. Annex, en la oficina de Compensación para el trabajador situada en 8240 Simon Gomez Rd, Lyford, TX antes de regresar a trabajar. Se le entregará al supervisor aprobación por escrito expresando condiciones y restricciones, si hay algunas, en el trabajo del empleado. Cualquier empleado que esté ausente del trabajo será puesto concurrentemente en Licencia de Ausencia Médica Familiar (FMLA). Si califica, FMLA es una protección de trabajo por hasta 12 semanas de ausencia. Los pagos del seguro deberán hacerse en el Departamento de Seguros de Lyford CISD antes del día 1° de cada mes para mantener el seguro en vigor. Si el empleado no paga las primas del seguro, el seguro será cancelado. No se hará substitución de ausencia pagada a ningún empleado que recibe beneficios de compensación del trabajador durante una ausencia designada por (FMLA).

Esto significa que un empleado que recibe beneficios por compensación del trabajador no puede recibir licencia local o estatal por enfermedad, días extendidos o donados mientras que esté en Licencia de Ausencia Médica Familiar. Si un empleado está ausente menos de 8 días, no recibirá beneficios de compensación del trabajador. Así que, durante esos 7 días, el empleado puede ser elegible para beneficios de licencia por enfermedad. Si no hay beneficios pagados, o cuando la licencia por enfermedad a vencido, el empleado será rebajado de pago por día o por hora, con posible excepción de licencia por asalto. Un empleado que es asaltado fisicamente durante el desempeño regular de sus labores deberá informar a su supervisor. Bajo ciertas circumstancias, si el empleado está fuera de trabajo por un periodo extendido de tiempo y no prevee un regreso al empleo, el/ella puede extender el cubrimiento del seguro por un maximo de 18 meses desde la fecha de separación de empleo, sin afectar los beneficios de compensación del trabajador, bajo los derechos de Continuación Federales, el Acto Reconciliado Presupuesto Consolidado Omnibus de 1985 (COBRA). Explicación completa de derechos se cubre en el libro del plan de grupo de beneficios para empleados.

COMPENSACION DE SEGURO CONTRA DAÑOS El Departamento de Seguros de Texas (TDI) describe nuestro seguro contra daños para el empleado lesionado o enfermo sin respeto a falta o negligencia si un empleado lesionado del Lyford CISD se sale del curso y alcance de empleo.

BENEFICIOS PARA LOS EMPLEADOS LESIONADOS

Beneficios Médicos

Un empleado lesionado tiene derecho a todos los beneficios médicos razonables y necesarios que promueven la recuperación o dan realce a la habilidad para trabajar. Todos los beneficios médicos deben ser aprobados o recomendados por el médico tratante de la lista de Alliance. Un empleado lesionado también tiene derecho a recibir todo el medicamento necesario según sea recetado por su médico que le atiende.

Los empleados del Lyford CISD pueden escoger a su médico de la lista de Alliance. Si desea cambiar doctor después del primer doctor escogido, SOLAMENTE puede escoger de la lista de doctores aprobados por PSWCA (The Alliance). Si desea cambiar doctor por tercera vez, tendrá que recibir aprobación del ajustador antes de cambiar.

La oficina de la compensación al trabajador del distrito puede ser contactada por proveedores médicos para autorización o verificación de pago de beneficios médicos por una lesión de compensación al trabajador. Esto usualmente ocurre en una situación de emergencia para el cuidado inicial.

Bajo situaciones de emergencia el Representante de Compensación de Trabajadores verificará que una lesión relacionada con trabajo a sido reportada pero no autorizará o negará tratamiento. La responsabilidad de aceptar o negar tocante a la compensación cae sobre el proveedor.

Prescripción

Texas Association of School Boards está trabajando junto con Progressive Medical, Inc. para proveerle al trabajador accidentado con el programa de tarjeta de medicamento llamada First Fill. La tarjeta de medicamento permitirá al trabajador obtener el medicamento inicial después del accidente, con poco ó sin ningún costo de su parte. Si su reclamo es aceptado, recibirá por correo una tarjeta de medicamento llamada “Retail Drug Card”. Presente esa tarjeta para medicamentos subsecuentes y relacionados a su accidente.

Beneficios de Ingresos

El Departamento de Seguros de Texas – División de Compensación para el Trabajador remplazará una porción de su ingreso semanal si no puede cumplir con sus labores regulares debido a una lesión o accidente relacionado con el trabajo.

a) Si su ingreso es menos de $8.50 por hora, recibirá el 75% del promedio de su ingreso semanal con ciertas restricciones.

b) Si su ingreso es más de $8.50 por hora, recibirá el 70% del promedio de su ingreso semanal con ciertas restricciones.

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE

JURISDICTION JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

EMPLOYER (NAME & ADDRESS INCL ZIP)

LOCATION #

INDUSTRY CODE EMPLOYER FEIN

EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)

PHONE #

CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)POLICY PERIOD

TO

CHECK IF APPROPRIATE

SELF INSURANCE

CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE

SEX MARITAL STATUS OCCUPATION/JOB TITLE

M U UNMARRIED SINGLE/DIVORCED EMPLOYMENT STATUS

F M

ADDRESS (INCL ZIP)

U

MALE

FEMALE UNKNOWN S

MARRIED SEPARATED

KPHONE # OF DEPENDENTS UNKNOWN NCCI CLASS CODE

YES RATE PER:

DAY WEEK

MONTH OTHER:

DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES

NO NO

OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK

AM

PM

DATE OF INJURY/ILLNESS TIME OF OCCURRENCE

( ) CANNOT BE DETERMINED

AM

PM

LAST WORK DATE DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S PREMISES?

TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE

YES NODEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL

CAUSE OF INJURY CODE

NODATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

WERE THEY USED?

YES

YES NO INITIAL TREATMENT

0

1

2

3

4

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

5

NO MEDICAL TREATMENT

MINOR: BY EMPLOYER

MINOR CLINIC/HOSP

EMERGENCY CARE

HOSPITALIZED > 24 HOURS

FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

OTHER WITNESSES (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER’S NAME & TITLE PHONE NUMBER

FORM IA-1(r 1-1-02) SEE BACK FOR IMPORTANT INFORMATION IAIABC 2002

13

PO. Box 220 / Lyford, TX 78569 / (956) 347-3902 / FAX (956) 347-3922 WC limited Modified duty

To: Doctor/Health Provider

From: Lyford CISD Workers’ Compensation Office

Date:

Re: Limited/Modified Duty

Lyford Consolidated Independent School District may provide limited/modified duty to employees that are injured and cannot immediately return to their regular jobs. Depending on the restrictions, the district may be able to accommodate the employees under the limited/modified duty provided in the work status report.

We ask that you consider identify the portion of his or her job that cannot be performed during the recovery period. The purpose of this is to allow employees to return to work in a limited/modified capacity until fully recovered and also to control the school district’s Workers’ Comp cost.

Please complete Part III of the Texas Workers’ Compensation Work Status Report (DWC-73) and indicate the restrictions, if any, so that we can assign Limited/Modified duty if possible.

We look forward to working with you to return employees to work under Limited/Modified duty. If there is any questions or if you wish to discuss any of these concerns, please contact Rolando Flores at (956) 347-3902 ext. 233.

I have received information that tells me how to get health care under my employer’s workers’ compensation coverage. If I am hurt on the job and live in a service area described in this information, I understand that:

1. I must choose a treating doctor from the Alliance list of doctors designated as treating doctors.2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor

will refer me. If I need emergency care, I may go to any licensed medical professional within the UnitedStates.

3. Even though my treating doctor should refer me to a specialist of providers contracted with the Alliance, Iunderstand that I need to verify that the referral doctor is a member of the Alliance provider panel.

4. The Texas Association of School Boards Risk Management Fund will pay the treating doctor and otherAlliance providers for all health care related to my compensable injury.

5. I may have to pay the bill if I receive health care from a provider other than an Alliance provider withoutprior approval from the Fund.

6. Making a false or fraudulent workers’ compensation claim is a crime that may result in fines and orimprisonment.

7. If I want to change doctors after my first choice, I can only choose from the Alliance list of providers. Athird choice requires approval from my adjuster.

_____________________________________________________ / / Signature Date

Printed Name

Address: Street Address

City, State, Zip Code

Name of Employer: LYFORD CISD

Name of Direct Contracting Program: Political Subdivision Workers’ Compensation Alliance (the Alliance)

Direct contracting service areas are subject to change. To locate a treating doctor within your area, visit the PSWCA web site at www.pswca.org or call your adjuster at 1-800-482-7276.

To be completed by the employer only

Please indicate whether this is the:

Initial Employee Notification Injury Notification (Date of Injury: / / ).

DO NOT RETURN THIS FORM TO THE TASB RISK MANAGEMENT FUND UNLESS REQUESTED.

EMPLOYEE ACKNOWLEDGMENT OF THE ALLIANCE DIRECT CONTRACTING PROGRAM

RECONOCIMENTO DEL EMPLEADO PARA EL PROGRAMA DE CONTRATAR DIRECTAMENTE CON MEDICOS

He recibido la información que explica como obtener tratamientos médicos si me lastimo en el trabajo. También entiendo si me lastimo en el trabajo:

1. Tengo que escoger un doctor de la lista de Alliance (PSWCAA), que son designados para tratar.2. Tengo que ir al doctor escogido por mí para tratamiento relacionado a mi lastimadura. Si necesito un

especialista, el doctor que escogí tiene que referirme a ese especialista. Si necesito tratamientos deemergencia, yo entiendo que puedo ir a cualesquier doctor licenciado en los Estados Unidos.

3. Si el doctor que escogí me refiere a un especialista, tengo que verificar que el especialista también esaprobado por la PSWCA.

4. La compañía TASB le pagará al doctor escogido por mí y a doctores también que son partidos de PSWCA.5. Si voy a un doctor que no es aprobado por TASB, y no pertenece al partido de la PSWCA, y no he obtenido

aprobación, entiendo que es posible que tendré que pagar esa cuenta.6. Reportando un reclamo falso de lastimadura en el trabajo es un crimen que puede resultar en multas o

encarcelamiento.7. Si deseo cambiar doctor después del primer doctor escogido, nada mas puedo escoger de la lista de doctores

aprobados por PSWCA. Si deseo cambiar doctor por la tercera vez, tendré que recibir aprobación de miajustador de la compañía TASB, antes de cambiar.

Firma: Fecha:

Nombre en imprenta:

Dirección:

Ciudad, Estado, y Código Postal

Nombre de empleo: LYFORD CISD

Nombre del programa de contratar doctores directamente: Political Subdivisión Workers’ Compensation Alliance (The Alliance PSWCA)

El servicio de contratar doctores directamente en las áreas de servicio, están subjetivos a cambiar. Para localizar un doctor de tratamiento en su área, visite al Internet en: www.pswca.org o llame a su ajustador al numero: 1-800-482-7276.

Solamente para uso del distrito

Please indicate whether this is the:

Initial Employee Notification Injury Notification (Date of Injury: / / ).

DO NOT RETURN THIS FORM TO THE TASB RISK MANAGEMENT FUND UNLESS REQUESTED.

Emp Description of Injury

EMPLOYEE DESCRIPTION OF INJURY DESCRIPCION DE LESION DEL EMPLEADO

Employee Name / Nombre del Empleado Campus / Dept – Escuela / Depto

Date of Injury / Fecha de Lesión Time of Injury / Hora que paso Lesión

Date Reported to Supervisor / Fecha Reportada al Supervisor

Description of my injury including all body parts affected and equipment/material used: Descripción de mi lesión incluyendo todas las partes de mi cuerpo afectadas y material/equipo usado:

Employee Signature / Firma del Empleado Today’s Date / Fecha de hoy

Lyford CISD Workers’ Compensation Supervisor’s Incident Investigation Report

This form is for recordkeeping and loss control purposes. Do not send this form to TASB or to the Texas Department of Insurance, Division of Workers’ Compensation. Using this form will benefit you in three ways: Incident Investigation assists you in reducing or preventing future occupational injuries and illnesses. This form requests all the information that DWC says you must record for each on-the-job injury, fatality, and occupational disease. Employers must keep injury records for five years after the last day of the year in which the injury occurred. This form is a good source of information if you need to complete a first report of injury. You must file a first report of injury with your insurance carrier for each on-the-job injury.

THIS INCIDENT is an Injury Incident Disease Fatality Near-miss

Today’s Date __________ _ _ _ District LYFORD CISD Supervisor __________________________________

Date Reported _______________ ____________________ Campus/Dept ____________________________________ Phone No. (956) _______________________________

1. Name of person involved 2. Sex 3. Social Security Number 4. D.O.B. _ / /__ _

5. Date of incident_ / /__ _

6. Home address____________________________________

____________________________________ Phone (956) _________________________

7. Time and day of incident a.m.; p.m.; _day of week

8. Specific location of incident __________Was it on employer’s premises? yes no

9. Employee’s occupation_____________________________ _____________________________

10. Job task at time of incident _________________________________ _________________________________

13. Name and address of treating physician(from The Alliance Network) ____________________________________

____________________________________

____________________________________

Phone ______________________________

11. Length of service_____________years ___________months

12. Employee was working alone with fellow workers Other _________________________

14. Employment category Regular, full-time Temporary Regular, part-time Seasonal Non-employee

15. Experience in occupation at time ofincident

Less than 1 month 1 to 5 months 6 months to 1 year 1 to 5 years more than 5 years

16. Name and address of hospital____________________________________ ____________________________________ ____________________________________

17. Phase of employee's workday at time of injury During break period During meal period Working overtime Entering or leaving the building Performing work duties Other (explain) ___________________________________________________

____________________________________________________________________________________

18. Employee's wage (pay per hour) $_______ per hour_

19. Name of employee's immediate supervisor at time of incident____________________________________________ Witnessed incident?

yes no 20. Voluntary benefits paid by the employer,(if any)

21. Other witnesses______________________________________________________________ ______________________________________________________________

22. Part of body injured or affected □ Right □ Left □ Right □ Left □ Right □ Left □ Right □ Left □ Right □ Left Skull, Scalp Jaw Eye Shoulder Wrist Knee Foot Abdomen Neck Back Upper Arm Hand Thigh Toe Nose Spine Pelvis Elbow Finger ______ Lower Leg Ankle Mouth Chest Ear Forearm Hip Other

23. Nature of injury or illness Puncture Bruise, Contusion skin Disorder Amputation Muscle Sprain Cumulative Trauma Disorder Laceration Fall Burn Insect/Animal Bite Muscle Strain Irritation Fracture Abrasion Respiratory Foreign Body Hernia Infection Head/Cold Stress Hearing Loss Chemical Exposure Other

Lyford CISD Workers’ Compensation Supervisor’s Incident Investigation Report 24. Disposition

Days away from work Restricted work days _____________ Date returned to work

Sent to Doctor Hospital

25. Diagnosis ___________________________ ___________________________ ___________________________

26. Severity First Aid Medical Treatment Lost Work Days Fatality Other

27. What condition of tools, equipment, or work area contributed to incident? Not applicable

Close clearance congestion Floors / Work surfaces Inadequate housekeeping Defective tools / equipment / vehicle Hazardous placement Inadequate ventilation Equipment failure Illumination Inadequate warning system Equipment / Workstation Design Inadequate guards / barriers Inadequate / improper P.P.E.

28. What caused or influenced substandard conditions? No substandard conditions

Abuse or misuse Inadequate supervision Inadequate purchasing Inadequate engineering Inadequate maintenance Inadequate tools / equipment / materials Improper work surfaces Wear and tear Lack of knowledge / training Improper motivation Inadequate capacity Lack of skill

29. What action or inaction contributed to the incident? Not applicable

Failure to make secure Under influence drugs/alcohol Failure to warn/signal Inadequate/Improper P.P.E use Nullified safety/control devices Used defective equipment Horseplay/distractive action Operating at improper speed Used equipment improperly Improper lifting Operating procedure deviation Running/rushing/acting in haste Improper loading Unauthorized actions Used wrong tool/equipment None Improper technique Improper position Servicing operating equipment Other

30. Probable recurrence Frequent Occasional Rare

31. Loss severity potential Major Serious Minor

32. Preventive measures: what corrective actions have been taken or are planned to prevent a recurrence? Improve enforcement Improve clean-up procedures Repair/replace equipment Corrective counseling Improve storage/arrangement Rotation of employee Eliminate congestion Improve/change work method Identify/Improve P.P.E. Install/revise guards/devices Task analysis Procedure revision Improve design/construction Job reassignment of employee Use other materials/supplies Improve illumination Mandatory pre-job instruction Improve ventilation Reinstruction of employee Other

33. Employee’s description of incident (attach sheet for additional comments) Comment sheet attached

Signature of Employee

34. Supervisor’s description of incident (attach sheet for additional comments) Comment sheet attached

35. Specific corrective actions or preventive measures taken

Corrective Action Taken Person Responsible Target Date Date Completed

___________________________ _

Supervisor’s Signature Date Manager’s Signature Date ___________________________ _____________ Safety Coordinator’s Signature Date

PO. Box 220 / Lyford, TX 785669/ (956) 347-3901 / FAX (956) 347-3921 WC Medical Release

EMPLOYEE MEDICAL RELEASE AUTHORIZATION I ID #

am reporting a work related injury that occurred on Date

I have been advised by the Lyford CISD Risk Management Department or their Representative that I have the right to visit the physician of my choice from the Alliance provider list; however, my injury is such that I am _____ or am not ______ in need of medical attention at this time.

I understand this does not prevent me from seeking medical advice and/or treatment at a later date.

Employee’s Signature Date

Authorized Signature Date

***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** *****

AUTORIZACION MÉDICA DEL EMPLEADO

Yo ID #

Estoy reportando una lesión que ocurrió en Fecha

He sido aconsejada/o por el departamento de control de peligro de Lyford CISD o su representante que tengo el derecho de visitar un médico de mi opción de la lista de proveedores de la Alianza, sin embargo, mi lesión es tal que yo estoy_____ o no estoy_____ en necesidad de atención médica en este tiempo.

Entiendo que esto no evita que busque consejo y/o tratamiento médico en una fecha futura.

Firma del Empleado Fecha

Firma Autorizada Fecha

PO. Box 220 / Lyford, TX 78569 / (956) 347-3901 / FAX (956) 347-3921 WC Ambulance Release

EMPLOYEE AMBULANCE RELEASE AUTHORIZATION

I ID #

am reporting a work related injury that occurred on . I have been advised by the Lyford CISD Risk Management Department or their Representative that I have the right to visit the physician of my choice from the Alliance provider list; however, I feel that an ambulance is ______ or is not ______ necessary at this time.

Employee’s Signature Date

Authorized Signature Date

***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** ***** **

Autorización del Empleado para el uso de la Ambulancia

Yo , ID #

estoy reportando una lesión que ocurrió en . He sido aconsejado/a por el departamento de control de peligro de Lyford CISD o su representante que tengo el derecho de visitar un médico de mi opción de la lista de proveedores de la Alianza, sin embargo, siento que una ambulancia es_____ o no es_____ necesaria en este tiempo.

Firma del Empleado Fecha

Firma Autorizada Fecha

PO. Box 220 / Lyford, TX 78569 / (956) 347-3901 / FAX (956) 347-3921 WC Nurse’s Report of Accident

NURSE’S REPORT OF INJURY Campus/Location of Accident:

Date of Accident Time of Accident:

Name of Nurse: ( ) RN ( ) LVN

Employee Name: ID #

Date of Vital Signs taken:

B/P / Temp: Respiration: Pulse:

Description of Accident: Employee alleges:

Body Part(s) Affected:

Evaluation of Injury:

First Aid Administered:

Instructions:

Name of Employee’s Doctor/Hospital:

Do you have any safety suggestions?

Nurse Signature Date

PO. Box 220 / Lyford, TX 78569 / (956) 347-3901 / FAX (956) 347-3921 WC Witness Report

WITNESS REPORT OF ACCIDENT (Reporte del Testigo del Accidente)

Campus / Location of Accident: (Escuela / Localidad del Accidente)

Name of Injured Employee: (Nombre del Empleado Lesionado)

Witness Name: ID # (Nombre de Testigo) (Número de identificación)

Home Address: (Domicilio)

City: Phone: (Ciudad) (Número Teléfonico)

Date of Accident: Time: am / pm (Fecha del Accidente) (Hora)

Place Accident Occurred: ( ) Classroom ( ) Hallway ( ) Cafeteria (Lugar donde ocurrió Accidente) (Salón de clase) (Pasillo) (Cafetería)

( ) Other: (Otro)

Description of Accident: (Descripción del Accidente)

Description of Injury: Indicate Body Part (s) Affected: (Descripción de la Lesión: Indique las partes del cuerpo afectadas)

__________________________________________________________________ __________

Could Accident Have Been Prevented? ( ) YES ( ) NO (Pudo ser prevenido el Accidente?)

If yes, how: (Sí si, Como)

______________________________________________________________________________

Do You Have Any Safety Suggestions? Tiene alguna Sugerencia de Seguridad?

___________________________________Witness Signature (firma del testigo) Date Supervisor Signature Date

PO. Box 220 / Lyford, TX 78566 / (956) 347-3901 / Fax (956) 347-3921 WC Medical Consent Form

MEDICAL CONSENT FORM AUTHORIZATION FOR MEDICAL RECORDS AND REPORTS

To Whom It May Concern:

I hereby authorize you to furnish Lyford C.I.S.D. or it’s representative, all medical information with respect to illnesses, injuries, medical histories, consultations, prescriptions, treatments, including x-ray films and copies of all hospital and medical records you have concerning the below named employee. A Photostat copy of this authorization shall be considered as effective and valid as the original.

Your assistance and full cooperation is appreciated.

Full name of employee (Please print or type)

ID# Telephone # (956)

Address: City:

State: Zip Code:

Employee Signature: Date:

By the above signature of the employee, he/she also agrees to the following:

• Follow all post-injury procedures and accept restricted work activity/modified duty positions,which confirm medical restrictions established by the treating physician, if they arerecommended and provided to him/her.

• Follow doctor’s orders, keep all medical appointments, be available to meet/talk with LyfordCISD or case management representatives and will attend meetings as directed.

• Once the treating physician has released the employee (in writing) to modified duty orregular work, the employee is required to return to work. Failure to do so will be considereda resignation of employment.

PO. Box 220 / Lyford, TX 78566 / (956) 347-3901 / Fax (956) 347-3921 WC Reporting of Employee Absence

REPORTING OF EMPLOYEE ABSENCE

1. If an employee misses work due to this reported injury, he/she must call his Supervisor andlet the supervisor know.

2. If an employee is out for more than 5 working days, employee must call JessicaCandelario at (956) 347-3901, to check in once a week.

3. If an employee is absent from work again due to the same injury, the employee must report itto his/her Supervisor.

______________________________ / ________ Employee Signature Date

*** *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** ***

REPORTANDO AUSENCIA DE EMPLEADO

1. Si el empleado falta al empleo a causa de esta lesión reportada, el/ella debe telefonear a suSupervisor y enterarle.

2. Si el empleado está ausente por más de 5 días hábiles de trabajo, el empleado debetelefonear a Lucy Esparza al (956) 347-3901, para reportarse una vez por semana.

3. Si el empleado está ausente del empleo otra vez debido a la misma lesión, el empleado debereportarlo a su Supervisor.

_______________________________ / ________ Firma del Empleado Fecha

WC Employee Choice

EMPLOYEE CHOICE TO USE PAID LEAVE WITH WORKERS’ COMPENSATION BENEFITS

Name ID #

Position Department/Campus

This employee is absent from duty because of a job-related illness or injury beginning on . If eligible, workers’ compensation insurance may begin paying a

percentage of the employee’s current wages on the eighth day of absence from duty if an extended absence is required.

District authorized signature Date

Employee choice:

I am absent from duty because of a job-related illness or injury. I understand that I am not eligible for workers’ compensation weekly income benefits until my absence exceeds seven calendar days. I choose the following option:

□ I choose to use only ______ days of available paid leave at this time.

□ I choose to use all available paid leave. I understand that I will not receive workers’compensation weekly income benefits until I have exhausted all of my paid leave or tothe extent that paid leave does not equal my pre-illness or -injury wage.

□ I choose NOT to use any available paid leave at this time. I understand that I will notreceive any regular salary payments from Lyford CISD while receiving weekly incomebenefits under workers’ compensation. No available paid leave will be deducted frommy leave balance. I further understand that by selecting this option, I will only receiveworkers’ compensation wage benefits for any absences resulting from my work-relatedillness or injury, unless and until I communicate to the district a change in my decision.

Employee Signature Date

WC Employee Choice (spanish)

LA OPCION DEL EMPLEADO PARA USAR DIAS PAGADOS CON BENEFICIOS DE COMPENSACION PARA TRABAJADORES

Nombre_________________________________________ ID. #____________________________

Posición________________________________ Departamento/Escuela______________________

Este empleado está ausente de su trabajo por una lesión o enfermedad relacionada con el trabajo empezando en _______________ (fecha del primer día ausente atribuido por enfermedad o lesión). Si es elegible, el seguro de compensación para trabajadores puede empezar a pagar un porcentaje del salario actual del empleado en el octavo día ausente del trabajo si una ausencia extendida se requiere.

________________________________________ ________________________________________ Firma autorizada por el distrito Fecha

Opción del Empleado:

Estoy ausente del trabajo por una lesión o enfermedad relacionada con el trabajo. Entiendo que no soy elegible para beneficios de ingresos semanales de compensación para trabajadores hasta que mi ausencia exceda siete días del calendario. Yo opto por lo siguiente:

□ Yo elijo usar solo ______ días disponibles pagados por ausencia en este tiempo.

□ Yo elijo usar todos los días disponibles pagados por ausencia. Yo entiendo que norecibiré beneficios de ingresos semanales de la compensación para trabajadores hastaque haya agotado toda mi ausencia pagada o hasta el punto en que la ausencia pagadano iguale mi salario de pre-lesión.

□ Yo elijo NO usar los días disponibles pagados por ausencia en este tiempo. Yoentiendo que no recibiré ningún pago por salario regular de Lyford CISD mientras estérecibiendo beneficios de ingresos semanales bajo la compensación para trabajadores.Ninguna ausencia pagada disponible será deducida de mi balance. Yo ademáscomprendo que al elegir esta opción, yo recibiré solamente beneficios de ingresos porcompensación para trabajadores por cualquier ausencia resultando de mi enfermedado lesión relacionada por el trabajo, solamente y hasta que yo le comunique al distritoun cambio en mi decisión.

_____________________________________________ ____________________________ Firma del Empleado Fecha

Progressive Medical’s First Fill® Program

1-888-908-MEDS For claim submission issues, prior authorization or claim rejections, please contact Progressive Medical, Inc. at 1-888-908-6337. Pharmacist: If you experience any problems, please call 1-888-908-6337. Disclaimer: It is important to note the issue will be determined by the claims department and the confirmation of this treatment/ service request is in no way intended as an endorsement of the treatment/service request, nor is it intended to interfere with the provider from his or her duty to adhere to any applicable practice standards.

When an injured party needs medication immediately, the First Fill option allows you to authorize these prescriptions and get them on the road to recovery.

Instructions for the Company

Fill in the ID/Auth# as instructed on the First Fill card below along with the name, date of birth and gender.

Instruct the injured party to take the First Fill card and their prescription to the pharmacy.

Report the claim to the appropriate insurance company/TPA. Note: If additional, ongoing medication is required, the claims professional should contact Progressive Medical to utilize our Retail Drug Card program. If additional First Fill cards are needed, or if you have any questions regarding the use of this program, please contact Progressive Medical at 1-888-908-MEDS and ask for the Pharmacy Services Coordinator.

Instructions for the Injured Party

Report your injury to the appropriate personnel.

At the bottom of this form is a First Fill card that will enable you to obtain the “initial” prescriptions needed upon injury with no out-of-pocket expense.

A sample list of “Participating Pharmacy Chains” that accept this First Fill card is included on the back.

Present your First Fill card and your prescription to the pharmacist.

This card is for a one time use to receive your medications per your employer/insurance company. Use of this card is restricted to your allowed condition.

If you have any questions, call Progressive Medical toll-free at 1-888-908-MEDS. Our Client Services Specialists are available 24-hours a day to take care of your needs.

PLEASE NOTE: IF YOUR WORKERS’ COMPENSATION CLAIM IS ACCEPTED, YOU WILL RECEIVE A RETAIL DRUG CARD IN THE MAIL. PRESENT THAT CARD WHEN FILLING SUBSEQUENT INJURY-RELATED PRESCRIPTIONS.

Questions? (888) 908-6337

Questions? (888) 908-6337

Phone: (800) 777-3574 Fax: (614) 923-7650 E-mail: marketing@progressive-medical.com Web: www.progressive-medical.com 101408

FIRST FILL® CARD

BIN#: Restat 600471

Company Name: Texas Association of School Boards

Group/Plan#: E127

Person Code: 00 (zero, zero)

ID/Auth#: SSN (9 digits, no dashes) Date (6 digits, no dashes) E.g. if the SSN is 000-00-0000 and today’s date is May 21, 2007, the ID/Auth# is 000000000052107.

Injured Party’s Name:

Date of Birth: Gender:

Progressive Medical’s First Fill® Program

Cuando una persona lesionada necesita medicamentos de inmediato, la opción con la tarjeta First Fill (Surtir primero) le permite autorizar estas recetas y ayudarle a recuperarse.

Instrucciones para la compañía

Anote el número de identificación/autorización en la tarjeta First Fill al verso junto con el nombre, la fecha de nacimiento y el sexo.

Indique a la persona lesionada que lleve la tarjeta First Fill y su receta a la farmacia.

Reporte la reclamación a la aseguradora/TPA apropiada.

Nota: Si se requiere recibir medicamentos adicionales continuamente, el profesional de reclamaciones debe ponerse en contacto con Progressive Medical para utilizar nuestro programa de Tarjeta de Medicamentos al por Menor. Si se necesitan tarjetas First Fill adicionales, o si tiene alguna pregunta sobre cómo usar este programa, llame a Progressive Medical al 1-888-908-MEDS y pida hablar con el Coordinador de Farmaceuta.

Instrucciones para el lesionado:

Reporte la lesión al personal apropiado.

Al verso aparece una tarjeta First Fill que le permitirá obtener los medicamentos “iniciales” necesarios para la lesión sin costo de su parte.

Recibirá una tarjeta First Fill para usar para recibir los medicamentos aprobados.

Presente su tarjeta First Fill y su receta al farmaceuta.

Recibirá los medicamentos sin costo alguno para usted.

Si tiene alguna pregunta, llame a Progressive Medical al (888) 908-6337. Nuestros coordinadores están disponibles las 24-horas al día.

NOTA: SI SE ACEPTA SU RECLAMO DE COMPENSACIÓN DEL SEGURO OBRERO, RECIBIRÁ POR CORREO UNA TARJETA DE FARMACIA AL POR MENOR. PRESENTE ESA TARJETA AL SURTIR RECETAS SUBSECUENTES RELACIONADAS CON EL TRABAJO.

Sample Listing of Participating Pharmacies

The following is a sampling of 64,000 participating pharmacies accessible through our program:

Albertsons Longs Drug Stores Duane Reade Safeway Giant Eagle Pharmacy Winn Dixie Pharmacy Meijer Pharmacy Publix Pharmacy CVS Pharmacy Walgreens Rite Aid Pharmacy Eckerd Drugs K-Mart Fred Meyer Target Pharmacy Tops Markets Medicine Shoppe Wal-Mart Pharmacy

For additional pharmacies within your area, call Progressive Medical’s Client Services department at 1-888-908-6337 or visit our Web site at www.progressive-medical.com. Go to the Workers’ Compensation tab and click on Total Pharmacy Management then select Pharmacy Locator. Enter your city, state or zip code and click on “Locate.” You will see a listing of pharmacies located within your area.

¿Preguntas? (888) 908-6337

¿Preguntas? (888) 908-6337

Phone: (800) 777-3574 Fax: (614) 923-7650 E-mail: marketing@progressive-medical.com Web: www.progressive-medical.com 101408

250 Progressive Way Westerville, Ohio 43082

(800) 777-3574 (614) 794-3300 Fax (614) 794-9582

e-mail: progressive@progressive-medical.com www.progressive-medical.com

Progressive Medical, Inc. están trabajado juntos para proveele al trabajador accidentado con el programa de tarjeta de medicamento llamada First Fill®. En la parte baja de este formulario se encuentra la tarjeta de medicamento que permitirá al tabajador obtener el medicamento inicial después del accidente, con poco ó sin ningún costo de su parte. Una lista de Cadenas farmaceuticas, que participan con este programa, ha sido incluida al reverso de esta tarjeta.

Instrucciones para la compañia sobre el uso de la tarjeta First Fill® • Accidente ocurre y empleado reporta el accidente al personal apropiado• Provea el nombre del empleado, número social, fecha de accidente y fecha de nacimiento.• Despues de explicarle el uso de la tarjeta al empleado, por favor de le este documento.• Instruja al empleado que presente esta tarjeta junto con la prescripción a la farmacia.

(Refiera la lista de farmacias proveida con la tarjeta)• Reporte el accidente a la compañia de seguro apropiada.• La farmacia procesara los medicamentos y el cobro será enviado a Progressive Medical.• La tarjeta First Fill® unicamente puede ser usada una sola vez.

Por favor, de suma importancia: Si medicamentos adicionales sean necesarios, la persona encargada del caso en la compañia de seguro tendrá que contactar Progressive Medical para utilizar el programa de venta al menor de medicamentos.

Si más tarjetas de First Fill® son necesarias o si tiene preguntas en relación del programa, por favor contacte Progressive Medical al 1-888-908-MEDS(6337) y pregunte por el coordinador de First Fill®.

Instrucciones para el empleado accidentado acerca del use de tarjeta First Fill®: • Este formulario será utilizado una sola vez para cubrir medicamento(s) autorizados por su

compañia de seguro. • El uso de esta tarjeta es restrinjida unicamente para su compensasión de trabajo.• Para recibir los beneficios, presente esta tarjeta a una de las farmacias participantes (Una

lista de farmacias a sido provista en la parte posterior de este formulario). Debajo de esteformulario encontrará la tarjeta First Fill® que le permitirá obterer los primerosmedicamentos necesario por su accidente de trabajo con un mínimo o sin ningun costoalguno de su parte.

• Si tiene alguna pregunta, llame a Progressive Medical al 1-888-908-MEDS (6337). Nuestroscoordinadores están disponibles las 24 horas al día.

P.O. Box 220 / Lyford, TX 78569 / (956) 347-3901 / FAX (956) 347-3921 WC Acknowledgement

Employee

ACKNOWLEDGEMENT

DATE: CAMPUS: (Fecha) (Escuela)

EMPLOYEE NAME: (Nombre del Empleado)

I have received copies of: Acknowledgement (Yo recibí copias de): Workers’ Compensation Guidelines

Workers’ Compensation Guidelines – (Spanish) Employee Rights & Responsibilities Employee Rights & Responsibilities – (Spanish) DWC-1 First Report of Injury TX Workers’ Comp Work Status Report (Blank DWC-73) Limited/Modified Duty Emp. Acknowledgment of the Alliance Direct Contracting Program Emp. Acknowledgment of Alliance Direct Contracting Program – (Spanish) Employee Description of Injury Medical Release Ambulance Release Nurse Report Witness Report Medical Consent Form Reporting of Employee Absence Choice to use Paid Leave with Workers’ Comp Choice to use Paid Leave with Workers’ Comp – (Spanish Progressive Medical – WC Medication Card

from the Lyford CISD representative. (del representante de Lyford CISD).

________________________________________ Employee Signature (Firma del Empleado)

_________________________________________ Representatives’ Signature (Firma del Representante)