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Catholic Charities – Human Resources Department 775 Valley Road, Room 209 Clifton, New Jersey 07013
1. Medical Treatment
2. Document Accident
3. Call Gallagher
4. Send Report to HR
WORK RELATED INJURIES
For severe injuries, call 911 immediately! For non-emergencies an employee
can be seen at an agency’s approved Medical Service Provider. (See attached).
Notify either the health care service provider
this is a work related injury.
Employee Non-Vehicle Accident Report form - Needs to be completed as
soon as possible or a Vehicle Accident Report form for car accidents. (Please
be as detailed as possible when completing the report)
If the employee is unable to complete the report a supervisor
(Preferred) or co-worker may complete the report on their behalf –
both individuals are to sign form (the injured employee can sign at a
later date if necessary).
Call Workman Comp Carrier – During the business hours (M-F 8:30AM-
4:30pm) Human Resources will contact our workman comp carrier, Gallagher
Bassett, to report the injury. The accident report must be sent to the HR
Department or email [email protected] or via HR fax 973-333-6031.
Outside of HR Business Hours: Accidents must be reported in a
timely matter, a supervisor must contact Gallagher Bassett to report
the injury. Please be sure to get the Loss Number from the
representative before completing your claim over the phone – write
the loss number on the accident report.
Gallagher Bassett (Report an Injury): 877-509-3503
Have the completed accident report in hand when calling.
Send Report to HR-Desiree Garcia, HR Generalist [email protected] or
via fax 973-333-6031. Questions or Concerns call Desiree Garcia at 973-847-
9037 or Hope Eder, Director of Human Resources at 973-557-9217 or
Instructions: Please follow these steps to ensure work related injuries and/or illnesses are documented properly and reported in a timely manner to a supervisor, our workman comp carrier and the HR Department.
2
5. Additional Services
WORK RELATED INJURIES
Concentra Transportation Services
Concentra offers employees complimentary transportation for those
employees who have experienced a work related injury. If an employee has
been injured on the job and cannot drive themselves to Concentra or do not
have a vehicle, they can contact their local Concentra to request
transportation. See the attached instructions on How to Request
Concentra’s Transportation Service for work related injuries.
Concentra Telemedicine Services
Concentra Telemed is the first telemedicine product designed for work-
related injuries. Everything about it—from the easy check-in to the
thorough screening and diagnosis—is designed to make the occupational
injury process easier for employees. With Concentra Telemed, employees
can use their Smartphone’s or computers to talk to a licensed clinician
trained in occupational medicine without having to leave work or sit in a
waiting room. Using video conferencing, the clinician will diagnose,
recommend treatment, and even prescribe medication if the employee needs
it. It’s an easy way for employees to get the care they need while
minimizing the time away from their worksite.
What it treats?
First-Degree Burns
Minor Neck and back Strains/Sprains
Abrasions/Scrapes
Work-related rashes
Tendonitis/repetitive use injuries
Blood borne pathogen exposure
It can also be used for follow-up visits and rechecks. For any issues that
require physical exam or are considered severe the employee will b sent to
the Concentra Medical Center.
Be advised that any severe or life-threatening injuries/medical conditions
the employee should be sent to the nearest emergency room or call 911!
See the attached instructions on how to use Concentra Telemed Services.
If you have any questions or concerns regarding Concentra Transportation
Services and Telemedicine Services, please contact call Desiree Garcia at
973-847-9037 or [email protected] or Hope Eder, Director of Human
Resources at 973-557-9217 or [email protected].
Catholic Charities – Human Resources Department 775 Valley Road, Room 209 Clifton, New Jersey 07013
Employee Information Today’s Date: ________________
First Name: _______________________________ Last Name: _______________________________Age: _______________
Home Address: ___________________________________________________________________________________________
Phone #: ______________________________ Sex (Circle One): Male Female
Agency (circle one): Straight and Narrow DPD CFCS Department: __________________________________
Position: ___________________________________ Supervisor: _____________________________________________________
Status (Circle one): Full Time Part Time Per Diem Other: ____________________________
Does employee have outside employment? (Circle one) YES NO
If yes, please indicate the name of the company and the title: ___________________________________________________________
Injury Information
Date of Injury:_____________________ Time of Injury: ________________ AM/PM
Hours of employment: From: ___________To:____________What location did the injury occur (building)? _____________________
To whom was the injury reported (Name and Contact info): ____________________________________________________________
Was First-Aid provided to the employee? YES NO If yes, by whom? __________________________________________
Please describe First-Aid given to employee: _______________________________________________________________________
___________________________________________________________________________________________________________
Did employee work remainder of shift? YES NO Was the employee sent to the hospital? YES NO
Was the employee sent Home or to Agency’s Medical Service Provider (i.e. Concentra or Valley)? _____________________________
Did employee refuse medical treatment? YES NO If yes, please indicate why ____________________________________
___________________________________________________________________________________________________________
Witnesses(s) (Name and Contact info):____________________________________________________________________________
Please describe the accident/injury below (be specific):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Catholic Charities
Employee Non-Vehicle Accident Report Form
Catholic Charities – Human Resources Department 775 Valley Road, Room 209 Clifton, New Jersey 07013
Employee Accident/Incident Report Form (Cont’d)
Front Back
Additional Comments:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Employee Signature: ______________________________________ Date: _______________________________
Preparer Signature (if applicable): ____________________________ Date: _______________________________
Type of Injury Sustained
Please circle all that apply:
Right Side Left Side
Abrasion
Blow/Strike
Burn
Chemical
Cut
Puncture
Slip/Fall
Sprain/Strain
Other (Explain Below):
For HR Use ONLY
OSHA Reportable (circle one): YES NO
Loss #: _______________________________
Reported by: ___________________________
Date of report: __________________________
Uploaded to Paylocity:_____________________
RIGHT RIGHT LEFT
If you have experienced a work related injury, please go to:
238 Piaget Ave
Clifton, NJ 07013
Phone: 973-772-3930
Hours: Mon-Fri 8:00am to 7:00pm
OR
72 Hamburg Tpk.
Riverdale, NJ 07457
Phone: 973-835-7290
Mon-Fri 8:00am to 8:00pm, Sat. 8am-4pm, Sun 8am-2pm
All employees who experience a work related injury must go to the clinic immediately!
Forms needed for:
Authorization Form
Special instructions/comments: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Authorized by: Title:______________________________________________________ ___________________________________________________________Please print
Phone: ______________________________________________________________ ______________________________________________________Date
( ___________________________________________________ )
Authorization for Examination or TreatmentPatient Name: ___________________________________________________ Social Security Number:___________________________________________
Employer: ___________________________________ Date of Birth:
Location Number:
__________________________________________________
Work Related Physical Examination
Injury Illness Preplacement Baseline Annual Exit
Date of Injury DOT Physical Examination___________________________________
Special Examination Breath alcohol
Substance Abuse Testing (check all that apply) Preplacement Recertification
Regulated drug screen
Collection only Hair collect Asbestos Respirator
HAZMAT Medical Surveillance
Audiogram
Human Performance Evaluation Non-regulated drug screen Rapid drug screen
_________________ Other
_________________ Other
Preplacement Reasonable cause
Employee to pay charges Post-accident Random
Follow-up
Due to the nature of these specific services, only thepatient and staff are allowed in the testing/treatmentarea. Please alert your employee so that they can makearrangements for children or others that might otherwisebe accompanying them to the medical center.
Street Address: ______________________________________________________________________
Temporary Staffing Agency: ___________________________________
Billing (check if applicable)
Type of Substance Abuse Testing
(Copies of this form are available at www.concentra.com)
© 2008 Concentra Inc. All Rights Reserved. 06/08
(Patient Must Present Photo ID at Time of Service)
Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans.
Auth Pad FT CUC.pdf 3/18/09 9:56:47 AM
Concentra Transportation Service
©2018 Concentra, Inc. All rights reserved.
About this Service
1
After an employee is injured, every second counts. Quickly getting the right medical care is essential for a fast recovery, but getting to a doctor can be a challenge. Not every employee has a car, and arranging transportation for them takes valuable time out of your work day—and theirs.
At Concentra, we want it to be easy for your employees to get care when they need it. To help with this, we now offer complimentary transportation for your injured employees. We’ll pick them up at work, drop them off at their local Concentra or U.S. HealthWorks medical center and take them back.
How it works1. Employee is injured at work and reports injury to supervisor.2. Supervisor completes incident report and authorization for
treatment.3. Supervisor/employee calls local Concentra or
U.S. HealthWorks clinic to request transportation. When they call, they’ll need to provide:
• Employee name• Employee/supervisor phone number• Pick-up location
4. Employee/supervisor will get an SMS text message letting them know they’re getting a ride.
5. When the driver is on the way, the employee will get another SMS message with the ride details.
• Your <ride provider> driver <Driver First Name> (<star rating>/5 stars) <phone # to call to reach the driver> will be arriving in a <color> <car make/model> with license plate <XXXXXXX> to pick you up in <eta to pick-up> mins. Track your ride.
6. Driver arrives at scheduled pick-up location to take employee to the nearest Concentra or U.S. Healthworks medical center, then drops them off for care.
7. We will arrange the employee’s return transportation.
Transportation Provided for:Initial Injury Visits Only
All Injury-Related Visits
Concentra Transportation Service About this Service
2©2018 Concentra, Inc. All rights reserved. CTSOS 07/18
How you benefit > Fast access to expert care.
We’ll take your employees right to the medical center, making it easy for them to get care right away after they’re injured.
> Convenience.We provide curbside pick-up and drop-off, no smartphone app or tip required.
> Reduced time away from work. We take your employees to and from their appointment, with minimal wait time. No time spent on arranging transportation, and their time is only spent at the appointment.
> Safety and privacy.Rides are actively monitored and both employees and drivers have masked numbers for added protection and to prevent arrangement of transportation outside of the Concentra rides.
> Pleasant experience.Vetted drivers deliver a hassle-free experience, earning high marks from employees.
Ready to ride?Contact your local Concentra or U.S. HealthWorks medical center. We’ll be happy to arrange transportation for your employee.
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Concentra Telemed® is the first telemedicine product designed
for work-related injuries. Everything about it—from the easy
check-in to the thorough screening and diagnosis—is designed
to make the occupational injury process easier for you and your
employees. With Concentra Telemed, employees can use their
smartphones or computers to talk to a licensed clinician trained
in occupational medicine without having to leave work or sit
in a waiting room. Using video conferencing, the clinician will
diagnose, recommend treatment, and even prescribe medication
if the employee needs it. It’s an easy way for employees to get
the care they need while minimizing the time away from their
worksite.
Concentra
Telemed
How Telemed Works
1. Employee is injured at work and reports injury to supervisor.
2. Supervisor completes incident report and authorization for treatment.
3. Supervisor or nurse triage (if applicable) determines if visit is appropriate for telemedicine and offers to employee as an option.
4. Employee registers for Concentra Telemed via the Concentra Telemed app or ConcentraTelemed.com.
5. Employee requests a visit on either the app or ConcentraTelemed.com.
6. Employee connects with a care coordinator, who conducts check-in and registration.
7. If the employee’s injury is appropriate for telemedicine, care coordinator completes intake and hands patient off to the clinician.
8. The employee sees the clinician for diagnosis and treatment.
9. The employer is notified of next steps or case closure.
What do Employees Need to Use?
A. Authorization Form from Your Employer. • Email your authorization to [email protected]
or fax it to 844-371-8990
B. Access to a quiet, private location. The employee will
need this for their privacy.
C. A computer, smartphone, or mobile device with a
webcam and microphone. Concentra Telemed requires
video to work.
D. An internet connection and active email address. They’ll
need this to connect to their telemedicine visit.
If you need help or you’re having technical issues, call Concentra
Help Desk at 855-835-6337
How to Access ConcentraTelemed.com You’ll need a computer with a webcam and microphone. You can’t access ConcentraTelemed.com using a tablet or smartphone.
1. Make sure you have your photo ID ready.2. Go to your computer. 3. Open your web browser and go to ConcentraTelemed.com. 4. Sign up or log in. You’ll need to use your email address.5. Once signed into the system, please click on an available care
coordinator to start the visit.
After informing your supervisor or safety personnel of your work-related injury, and receiving clearance to obtain care via telemedicine, you are ready to start your visit with Concentra Telemed™. There are two ways you can access Concentra Telemed, using your web browser on your computer or with the Concentra Telemed app on Android and iPhone.
©Concentra® 2018. All rights reserved. 022719
Employee Instructions - Sign Up
Your Visit After you’ve signed up:
1. Select the option to start a visit with an available care coordinator. Depending on their availability, you may be added to a virtual “waiting room” while you wait for them to connect.
2. The care coordinator will ask you some questions about your medical history and why you’re visiting. 3. You’ll be queued in a virtual waiting room to see a doctor. If you need to step away, remember to click the box
that says TEXT ME so that you’ll be reminded when the clinician is ready. 4. Time for your appointment! Talk to the clinician as much as you need to. 5. When you’re done, you’ll check out with your care coordinator. They’ll help you get scheduled for another visit
if you need it.
How to Use the Concentra Telemed App To use the app, you’ll need a smartphone with a camera.
1. Make sure you have your driver’s license or state ID ready.2. Go to the Apple app store or Google Play app. Search for “Concentra
Telemed” and download the Concentra Telemed app. 3. Open the app. 4. Sign up or log in. You’ll need to use your email address.5. Once signed into the system, please click on an available care
coordinator to start the visit.
Please note: The Concentra Telemed platform and Concentra Telemed app are exclusively for employers who have established telemedicine accounts with Concentra for their employees.
Need help? Having technical issues? Call us at 1.855.835.6337.
What it treats
• First-degree burns
• Minor neck and back
strains/sprains
• Bruises/contusions
• Abrasions/scrapes
• Work-related rashes
• Tendonitis/repetitive use injuries
• Bloodborne pathogen exposure
It can also be used for follow-up visits and rechecks. Issues that
require physical exams or are considered severe will be sent to
a Concentra medical center, an in-network clinician, or to the
nearest emergency department for treatment. As always,
severe or life-threatening medical conditions should be sent to
the emergency department.
System and network
requirements
Mobile Access
Patients can access Concentra Telemed from their Android or
iOS mobile device by downloading the Concentra Telemed app
from Google Play or the App Store. For the best experience, a
Wi-Fi connection is recommended. Concentra Telemed can also
be accessed via cellular connection (3G/4G). You can check
your bandwidth by downloading and using the Speedtest by
Ookla app. For the best experience and quality, ensure that you
have a strong signal (4-5 bars) when connected to a cellular
network. To use Concentra Telemed on mobile, your device
must meet the requirements below.
• Concentra Telemed app installed (see above) • Device must have a front-facing camera (supports two-way video
visits) • Operating System - iOS (iOS 11.4 or later is required) • iPhone 5 and newer • iPad 4th Gen and newer • iPad Mini 2 and newer • iPod Touch 6th Gen and newer • Operating System - Android API 19 (KitKat v4.4.0 or above) • Android Phone • Android Tablet • Not supported: HTC myTouch, all Prestige devices, and the
PantechP9070
Web access
(PC/Mac/Laptop)
Concentra Telemed can be accessed from the web using any of
the browsers listed below. Both JavaScript and cookies must be
enabled in the browser settings.
Google Chrome (latest version recommended; one version prior supported)
Visit: http://www.google.com/chrome
Mozilla Firefox (latest version recommended; one version prior supported)
Visit: http://www.mozilla.org/en-US/firefox/new/
Safari (Mac ONLY: latest version recommended; one version prior supported)
Visit: http://www.apple.com/safari/download/
Microsoft Edge
Visit: https://www.microsoft.com/en-us/windows/microsoft-
edge
cation Details
