Index #: 303.04 Page 1 of 19 ADMINISTRATIVE POLICIES AND

Index #: 303.04 Page 1 of 19

Effective Date: March 15, 2020

Distribution: A

Supersedes: 303.04 (5/1/19) PCN 19-48 (7/15/19) Approved by: Tony Parker

Subject: WORKERS’ COMPENSATION CLAIMS AND RETURN TO WORK PROGRAM

I. AUTHORITY: TCA 4-3-603, TCA 4-3-606, TCA 9-8-307, and TCA 50-6-102. II. PURPOSE: To establish procedures for state employees to file workers’ compensation claims for

injuries arising out of the course of their assigned duties and within the scope of their employment and to establish a return-to-work policy and process.

III. APPLICATION: All employees of the Tennessee Department of Correction (TDOC). IV. DEFINITIONS: A. Assault Injury: An injury received by an employee in the performance of their assigned

duties as a result of bodily assault.

B. Authorized Healthcare Provider: The medical or mental health provider approved to treat a compensable occupational injury selected from the State workers’ compensation provider network.

C. Bloodborne Pathogens: Infectious microorganisms present in blood that can cause disease

in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV), the virus that causes AIDS. Workers exposed to bloodborne pathogens are at risk for serious or life-threatening illnesses.

D. Division of Claims Administration (DCA): An administrative unit of the Office of the

Treasurer established to promulgate rules and regulations to ensure orderly filing, investigation, hearing, and disposition of claims brought before it by or on behalf of an employee or against the State.

E. Healthcare Provider: Clinical staff who are legally authorized by licensure, registration, or

certification to perform direct healthcare services. F. Immediate Medical Treatment: The management and care of a patient by a licensed

medical or mental health provider (in a clinical setting or through tele-health services) for the purpose of combating disease, injury or disorder; to include but not limited to use of medication, immunizations, first aid, use of closing devices or immobilization devices, psychotherapy, physical therapy or chiropractic treatment, surgical procedures, etc. as prescribed by the medical or mental health provider.

G. Infectious Control Representative: Clinicians specially trained to help reduce the number

of patient infections in TDOC institutions and to help prevent the spread of communicable disease.

ADMINISTRATIVE POLICIES AND PROCEDURES State of Tennessee Department of Correction

H. Institutional Health Services Provider: Clinical staff who are legally authorized by

licensure, registration, or certification to perform direct or supportive health care services and whose primary responsibility is to provide clinical services to inmates in the custody of the TDOC. Examples of health care providers may include physicians, dentists, physician assistants, nurse practitioners, nurses, psychiatrists, psychological examiners, psychologists, clinical social workers, etc.

I. Occupational Injury: As defined by TCA 50-6-102, an injury by accident, a mental injury,

occupational disease, or cumulative trauma conditions arising primarily out of and in the course and scope of employment, that causes death, disablement or the need for medical treatment of the employee.

J. Return to Work Employment Action Plan: An agreement in writing drawn up between the

employee and the TDOC, with input from the authorized medical provider, to include details for temporary modified or temporary transitional duty assignments and which should be written to return the employee back to full potential as soon as possible. A copy of the return to work action plan will be placed in the confidential volume of the employee’s Human Resources file.

K. Safety Management Team (SMT): A team comprised of the TDOC Safety Officer, HR

staff, Workers’ Compensation Coordinator or any other individual in a leadership position within the TDOC to evaluate limitations and restrictions imposed by an employee’s authorized medical provider to determine feasibility of a temporary modified or temporary transitional duty assignment.

L. TDOC Safety Officer: The employee at each TDOC Facility, Community Supervision

District Office, or TDOC Central Office assigned to coordinate fire, building, and other safety concerns.

M. TDOC Site Manager: For the purpose of this policy only, Wardens for prisons,

Superintendents for the Tennessee Correction Academy (TCA), Superintendent/Warden for transition centers, District Directors for probation/parole offices, Correctional Administrators for day reporting centers, and the Human Resources Director for the Office of Investigation and Compliance (OIC), Major Maintenance, and Central Office; or Designee(s).

N. TDOC Work Location: Any worksite in the TDOC generally recognized as an identifiable

unit, including, but not limited to, correctional institutions, the Tennessee Correction Academy (TCA), transition centers, probation/parole offices, day reporting centers, the Office of Investigations and Compliance, Major Maintenance, and Central Office.

O. Temporary Modified Duty Assignment: A temporary reinstatement to the employee’s pre-

injury position with modification to tasks, functions, or hours. P. Temporary Transitional Duty Assignment: A temporary position consisting of

supplemental tasks not usually performed by the employee. Q. Third Party Administrator (TPA): The Company contracted by the Division of Claims

Administration to handle verification, approval, denial, and payment of compensable worker’s compensation claims (medical bills, pharmacy bills, and lost time pay).

Effective Date: March 15, 2020 Index # 303.04 Page 2 of 19


R. Workers’ Compensation Administrator: The individual designated to compile workers’

compensation reports, monitor activity, manage Workers’ Compensation Coordinators, determine necessary discipline to be recommended, and coordinate employee case management activity.

S. Workers’ Compensation Claim: A request by a state employee or the estate of a deceased

state employee for compensation of injuries received or death arising out of the course of their assigned duties and within the scope of their employment (whether such injury or death was accidental or otherwise).

T. Workers’ Compensation (WC) Coordinator: The Human Resources individual designated

at each TDOC work location to coordinate employee’s case management activity in relation to, their Workers’ Compensation Claim and the return to work program.

U. Workplace Injury and First Notice of Loss Call Center (Call Center): A center contracted by the TPA and manned by medical staff to determine level of care necessary and start the workers’ compensation claim process when an employee has an occupational injury.

V. POLICY: The TDOC will oversee the Workers’ Compensation and Return to Work Program to

ensure accurate reporting of work related incidents and to expedite the return of TDOC employees to their jobs as quickly as possible, following an occupational injury or non-work-related injury; and to place TDOC employees who are unable to return to their normal duties into a temporary modified or transitional duty assignment.

VI. PROCEDURES:

A. This policy shall be a part of new employee orientation. The training will be conducted by

an HR staff member or the WC Coordinator. Employees shall review Policy #303.04, and Notice of Employee Rights and Responsibilities in the Event of a Workplace Accident, Injury, or Illness, CR-3875, and sign the CR-3875. The signature page shall be placed in the employee’s Human Resources file, and the trainee shall retain the other information for future reference.

B. This policy shall be part of annual training and communicated to all staff;

acknowledgement of this annual training shall be signed and placed in the employees’ training files. Additional training may be provided for supervisors, Safety Officers and Human Resources personnel.

C. Posters shall be displayed throughout all TDOC work locations, denoting the Workplace

Injury and First Notice of Loss Call center phone number and procedures. All employees shall have access to workers’ compensation and return to work procedures and the statement of employee responsibilities.

D. The employee and their supervisor shall notify the Call Center at 1-866-245-8588, option

#1, immediately after the occurrence of an incident. The medical staff at the Call Center will determine the level of treatment that may be necessary to include but not limited to: first aid, telehealth services, treatment by a state approved medical provider, etc. (Failure to complete this step of the process within 24 hours of the occurrence of the incident could



result in fines being levied against the TDOC by the Tennessee Department of Treasury)

To complete the reporting process the supervisor can ask the registered nurse to transfer the call to the First Notice of Loss (FNOL) unit or directly call (866) 245-8588, option #2. The FNOL unit will ask the supervisor additional questions. If the supervisor is unable to answer the questions, Human Resources may be contacted for assistance. The supervisor must notify the WC Coordinator/designee of the incident prior to the end of his/her shift.

1. The employee may be provided with an approved panel of physicians in the TPA’s

network. If an employee seeks medical treatment from outside the network, medical bills will not be approved unless the situation is an emergency determined to be serious bodily injury or life threatening. State employee insurance is separate from workers’ compensation insurance, which is used in the case of occupational injuries. State employee insurance does not cover work related claims.

2. In the event of an occupational injury requiring immediate emergency treatment for

a serious or life-threatening condition, the employee shall be transported to the most convenient emergency facility and the supervisor shall contact the Call Center to report the incident to the TPA, prior to the end of the shift during which the incident occurred.

3. In the event of an assault injury an Accident Report, TR-0231, must be completed

and forwarded to the Workers’ Compensation Administrator within ten calendar days of the incident. The employee or the supervisor shall also contact the Call Center to report the incident to the TPA, prior to the end of the shift during which the incident occurred. See Policy #303.10, Assault Injury Pay.

4. The WC Coordinator shall ensure the employee is issued the Workers’

Compensation Notice of Receipt of Claim, CR-4116, within three business days of the date the claim was submitted to the TPA, either hand delivered or by certified mail and shall maintain a copy for the employee’s record.

5. The TPA will complete the FNOL within five business days. The WC Coordinator

shall monitor the TPA’s database and report any FNOLs open past the five day timeframe to the WC Administrator. If no medical treatment was sought the WC Coordinator shall close the claim.

6. The TPA will send a TPA’s Initial Treatment Guide - Physician’s Report to the

Authorized Medical Provider. If this guide is unavailable, the employee shall be given a Workers’ Compensation Medical Release or Work Status Report, CR-3873, to take to his/her authorized medical provider or the form may be sent to the authorized medical provider.

7. In the case of an occupational injury, the WC Coordinator will contact the injured

employee within 24 hours of or the next business day after notification of the accident and will contact the employee at least once a month until the employee returns to full-duty in their pre-injury position.

8. An employee shall be subject to drug and/or alcohol testing after an incident that

resulted in death, injury, or property damage. Post-Accident drug screens will be administered in compliance with Policy #302.12.



9. All employees must seek medical treatment within one year of the date of the

occupational injury.

10. No employee shall be refused the right to file a workers’ compensation claim. 11. An employee should immediately notify his/her supervisor of any work related

incident or injury no later than 24 hours of the incident. Failure to report the incident within 24 hours of occurrence and/or seeking medical treatment prior to reporting the incident may result in fines levied against the TDOC by the Tennessee Department of Treasury and will be reviewed on a case by case basis by the Workers’ Compensation Administrator to determine if possible disciplinary action could occur.

12. All incidents shall be reported to the TDOC Site Manager/Designee who will

notify TDOC Central Office in compliance with Policy #103.02. E. If the authorized treating medical provider determines the employee is unable to return to

perform any work responsibilities the WC Coordinator will explain to the employee their eligibility for workers’ compensation temporary total disability (TTD) lost time benefits. The employee shall be provided with a Notice of Intent for Lost Time Payment, CR-4092. The employee shall complete the CR-4092 and submit it to the WC Coordinator within seven calendar days of their first day of absence. Failure to return the completed form to the WC Coordinator may result in the use of the employee’s accrued leave for any time they missed from work. In compliance with TDOHR procedures, after indicating the intention to use leave instead of lost time benefits or failing to indicate a choice to use leave or lost time benefits, any leave used in lieu of lost time benefits cannot be reinstated.

1. An employee on leave must maintain weekly contact with their agency/supervisor.

Contact may be by phone call, in person, or other pre-arranged method. The employee shall be advised of the contact person and given the accurate contact information.

2. The employee must submit a medical status report to the WC Coordinator after

each medical visit.

F. Any prior approval for additional/outside employment is revoked during an employee’s TTD lost time benefits. An injured employee may engage in secondary employment while on TTD only if approved by the Safety Management Team and appropriate TDOC Site Manager in compliance with Policy #302.14, Additional Employment. If an employee is approved for and accepts outside employment, his/her TTD benefits may be reduced.

G. If an employee is given a prescription by their authorized medical provider, he/she should

follow the instructions of the TPA relative to the pharmacy benefits. A provider in the workers’ compensation network must be used. The employee shall not fill prescriptions to be billed to the employee’s state employee health insurance carrier. The employee should contact the WC Coordinator for additional information.



H. In case of an occupational injury, if the authorized medical provider believes the employee

can return to work with defined restrictions, the employee shall immediately provide a copy of the Workers’ Compensation Medical Release or Work Status Report, CR-3873, or other detailed work status report including details of the restrictions and limitations to the WC Coordinator. The employee shall be placed on a temporary modified or a temporary transitional duty assignment as long as a job is available within his or her restrictions and capabilities. Before the reissuance of a firearm to an employee who has previously been authorized to carry one, a physician or psychologist selected by TDOC, shall certify that the employee may be reissued the firearm and is fit for duty. See Policy #303.12.

1. The WC Coordinator must receive the Workers’ Compensation Medical Release or

Work Status Report CR-3873, TPA Physician’s Report, or other similar document detailing any physical or mental restrictions or limitations before a temporary modified or temporary transitional duty assignment can be considered.

a. If the authorized medical provider does not provide the requested

documentation the WC Coordinator should contact the TPA claims adjuster immediately for assistance in securing this documentation.

b. For a work related injury: Failure to offer the employee a temporary

modified or temporary transitional assignment, after he/she has been released to return to work with limitations or restrictions, may result in the TDOC being charged 50% of the cost of the employee’s TTD. The employee should be returned to work as soon as possible but no later than 14 days from the date of the medical release.

2. Temporary Modified Assignment: If the employee is able to perform most of the

functions of his/her job, the employee may return to their pre-injury position with modification to tasks, functions, or hours. The employee remains in his/her regular position and job classification and continues to receive regular wages and accrue benefits as usual. Wage and benefits are pro-rated, based on actual hours worked.

Any prior approval for additional employment is revoked during an employee’s temporary modified assignment. An injured employee may engage in secondary employment while on TTD or a temporary modified assignment only if approved by the SMT and appropriate TDOC Site Manager in compliance with Policy #302.14.

3. Temporary Transitional Duty Assignment: If the employee is unable to perform the functions of his/her pre-injury position, the employee shall be placed in a temporary transitional duty assignment consisting of supplemental tasks not usually performed by the employee, provided a job is available within his/her physical/mental abilities.

The SMT will identify supplemental tasks not usually performed by the

employee, but within his/her defined restrictions. A series of supplemental tasks will be assembled and combined to fill the employee’s allowed work time; supplemental tasks shall be meaningful in nature and contribute to the operational functions of the Department.



Any prior approval for additional/outside employment is revoked during an employee’s temporary transitional duty. An injured employee may engage in secondary employment while on a temporary transitional duty assignment only if approved by the SMT and appropriate TDOC Site Manager in compliance with Policy #302.14, Additional Employment. When an employee on initial probation is placed on a temporary transitional duty assignment the HR Manager/designee shall monitor the Edison database monthly and complete the required process to extend the probation end date as often as necessary. The probation date shall not be allowed to expire.

4. Temporary Modified or Transitional Duty Assignments are offered when there is

documentation that the employee cannot perform the functions of his/her pre-injury position, but is expected to recover from the injury within a reasonable period of time. The temporary assignment shall be limited to 180 days in most cases. If the injured employee is making satisfactory progress towards recovery or a release for full duty is anticipated within a reasonable period of time, the TDOC site manager may consider extending the modified assignment for another 30 days.

5. The following guidelines shall be followed for developing a modified or transitional duty assignment:

a. The WC Coordinator will consult with the SMT members to include the

employee’s temporary supervisor to assist with development of the task inventory for a temporary modified or temporary transitional duty assignment. The team may consult with the employee and/or the authorized medical provider when determining if a proposed temporary modified or temporary transitional duty assignment is suitable. The SMT should complete the return to work employment action plan and return the employee to work within seven business days of the date of the employee’s release to work, if possible. The employee must be returned to work within 14 days of release to prevent the TDOC from being charged 50% of the employee’s TTD.

b. The SMT will consider physical and mental requirements, job descriptions,

work environment, safety and security issues, employee competencies, and medical opinions of the authorized medical provider to determine if a temporary modified or temporary transitional duty assignment is available.

c. Every effort is made to place the employee in his/her current work location

and shift; however, if this is not possible, the SMT may seek an alternative work location within TDOC, or an alternative shift, as long as the conditions for return to work have been met.

d. Defined tasks shall be documented on the Task Inventory for Modified/

Transitional Duty Assignment, CR-3876, and signed by the employee and supervisor and approved by the appropriate TDOC Site Manager.



e. Changes in temporary modified or temporary transitional duty assignments

shall be made based on the authorized medical provider’s updated documented restrictions and limitations. As the employee recovers, the SMT shall suggest modification to the temporary modified or temporary transitional duty assignment job tasks to meet the employee’s increasing abilities.

6. If a temporary modified or temporary transitional duty assignment is offered to

an injured employee and the assignment is consistent with properly established medical restrictions, the assignment is treated no differently than reporting to a pre-injury job. a. Failure of an employee to accept a temporary modified or temporary

transitional duty assignment may prohibit the employee from collecting workers’ compensation TTD lost time benefits and may result in disciplinary action up to and including dismissal.

b. Supervisors should contact the local WC Coordinator immediately if an

employee refuses or fails to return or report to a temporary modified or temporary transitional duty assignment.

c. The WC Coordinator shall notify the TPA when a temporary modified or

temporary transitional duty assignment is offered to an employee with an occupational injury. The TPA should be advised of the exact date the employee is scheduled to return to work

d. If the employee believes they are unable to return to work after his/her

authorized absence has expired, the employee must notify the assigned supervisor and the WC Coordinator. The WC Coordinator shall contact the TPA for guidance. A re-evaluation with an approved medical provider may be requested.

7. Employees are expected to follow all TDOC and TDOHR rules and policies as

they relate to job performance and conduct. Failure to do so may result in disciplinary action. This includes following standard procedures for reporting absences from work. Employees shall notify supervisors as much in advance as possible of scheduled medical appointments. Supervisors should encourage employees to adhere to their medical treatment plan and make all efforts to arrange schedules as necessary for the employee to attend all scheduled medical appointments. If the employee is unable to schedule medical appointments outside working hours, the employee must use accrued sick, annual, or compensatory leave for these absences.

8. The supervisor should monitor the employee’s work performance to determine if

the temporary modified or transitional duty assignment is meaningful and the employee is contributing successfully to the operational functions of the Department. If the supervisor determines the employee’s work performance is deficient then the employee may receive progressive discipline, which includes termination of employment.



9. In the case of a work related injury, if the employee’s work performance is unacceptable due to reasons that are not related to their work restrictions/medical condition (attendance, cooperation, etc.), and the employee is removed from the temporary assignment or terminated the employee may not be eligible to receive TTD benefits.

10. If the employee’s restrictions become permanent, maximum medical improvement (MMI) is reached, and the employee is unable to perform the essential job functions of the pre-injury position, the TTD will normally be terminated. If the employee has reached MMI the HR staff will immediately notify the ADA Coordinator and the following steps should take place:

a. The ADA Coordinator will review the employee’s restrictions and

limitations to determine if a reasonable accommodation may be available that will allow the employee to perform the essential job functions of the pre-injury position. If no such reasonable accommodation is available after the review is complete the employee may be allowed 30 days of any eligible leave benefits to seek other employment.

b. The Human Resources staff may assist the employee with applying for

other State positions for which he or she qualifies. It is always the employee’s responsibility to actively participate in searching for and securing other employment.

c. If at the end of the 30 day leave period the employee has not secured other

employment, he or she may be separated for the good-of-the-service; any such separation would be in good standing and does not terminate eligibility for other benefits provided by the Tennessee Workers’ Compensation Act. Such separations must be reviewed by the Director of Human Resources/designee(s) and the General Counsel prior to being issued to the employee.

d. Prior to processing the above mentioned separation or upon return to work

from TTD the Human Resources staff shall assist the employee in completing Application for Retirement Credit for a Period of Temporary Disability under Workers’ Compensation, TR-0301, to restore any retirement credit lost while the employee was on TTD.

I. The temporary modified or transitional duty assignments described in Section VI.(H)

above will terminate when one of the following occurs:

1. One hundred and eighty consecutive calendar days have elapsed from the day the employee accepts the assignment.

2. The appropriate TDOC Site Manager determines based on the progress of the employee’s performance that the employee is unable to perform the work assigned.

3. The employee is released to regular full duty in his/her pre-injury position.

4. The temporary position is no longer available.



5. The employee is placed on permanent restrictions and/or has reached maximum

medical improvement, which prevents him/her from returning to the regular duties of the pre-injury position.

6. If the authorized medical provider determines that the injured employee should

not return to work; provides a work status report that does not allow the employee to work a temporary modified or a temporary transitional duty assignment; or provides indefinite or incompatible restrictions.

J. An employee exposed to bloodborne pathogens, in the course of their assigned duties,

should immediately notify his/her supervisor and/or the WC Coordinator by the end of the shift on which the exposure occurred. The employee and supervisor shall notify the Call Center to report the exposure. The medical staff at the Call Center will determine the level of treatment necessary and may provide the employee with an approved panel of physicians in the network.

1. An Occupational Exposure to Bloodborne Pathogen Follow-Up, CR-3508, shall

be completed by an Institutional Health Service Provider, TCA medical staff, or TDOC Site Manager at the time of the incident and a copy given to the employee to provide to the healthcare provider.

2. The WC Coordinator shall provide the following to be reviewed and/or

completed by the healthcare provider:

a. TDOC Bloodborne Pathogens 1910-1030 Handbook to be given to the medical provider.

b. Healthcare Provider Written Opinion Following Exposure to Bloodborne

Pathogen(s), CR-3857. The employee or the medical provider is to return the completed original form to the WC Coordinator within three days of the initial visit. A copy of the completed form must be given to the employee within 15 days of the initial evaluation.

c. Medical Written Authorization Leave/Return to Work Following

Exposure to Bloodborne Pathogen(s), CR-3856. After treatment, the employee must return this completed form to the WC Coordinator prior to returning to duty.

3. If an employee has been exposed to bloodborne pathogens in the course of their

assignment and refuses treatment, the supervisor shall report the incident to the Call Center and the WC Coordinator. The employee shall be required to sign the Informed Refusal of Medical Evaluation Following Exposure to Bloodborne Pathogen(s), CR-3858, and the WC Coordinator shall sign the form as witness.

4. The Infection Control Representative or Healthcare Provider should complete the

Post Exposure Incident Evaluation, CR-3503, within ten business days of the incident.

VII. ACA STANDARDS: 4-4041, 1-CTA-1B-09, AND 2-CO-1B-11.

VIII. EXPIRATION DATE: March 15, 2023.



TENNESSEE DEPARTMENT OF CORRECTION

NOTICE OF EMPLOYEE RIGHTS AND RESPONSIBILITIES IN THE EVENT OF A WORKPLACE ACCIDENT, INJURY OR ILLNESS

CR 3875 (REV.01‐20) RDA SW03 Page 1 of 4

Employee Name (Print): As an employee of the Tennessee Department of Correction there are certain rights and responsibilities you have as it relates to a workplace incident or an occupational injury.

1. Report all incidents to your supervisor immediately, even if no one is injured. All incidents should be reported prior to the end of the shift in which they occurred, but no later than within twenty-four (24) hours of the incident. Failure to report incidents within 24 hours of occurrence will be reviewed on a case by case basis and possible disciplinary action could occur.

2. Cooperate and/or participate in the reporting, analysis, investigation, and system improvements of all incidents.

3. Utilize the Workplace Injury and First Notice of Loss Call Center (1-866-245-8588 option #1) to report all incidents. Your supervisor or the Worker’s Compensation (WC) Coordinator in Human Resources can assist with this process. The medical staff of the Call Center will determine the level of treatment that may be necessary to include:

A. First Aid B. Telehealth Services (this service is optional and you may choose to see a

physician instead) C. Medical Treatment from an approved in network provider. (You may be provided with a panel of physicians in the network to

choose from.) D. Emergency treatment – if your injuries are serious life threatening injuries you

may be transported to the most convenient emergency facility. 4. If you fail to report the incident and/or seek treatment from outside the physician

network or seek treatment prior to reporting the incident, your medical bills may not be approved for payment (except in an emergency determined to be life threatening.)

5. State employee medical insurance does not cover on-the-job-injuries. 6. The WC Coordinator may give you a Worker’s Compensation Medical Release or

Work Status Report CR3873 to take to your medical provider – take this form with you for your medical appointment(s).

A. Have your medical provider complete the Medical Release –Work Status Report form for authorized leave or for a modified/transitional work assignment. ONLY THIS FORM OR ONE WITH SIMILAR INFORMATION FROM YOUR APPROVED MEDICAL PROVIDER WILL BE ACCEPTED AS DOCUMENTATION OF AUTHORIZED MEDICAL LEAVE OR TO DEVELOP A TEMPORARY WORK ASSIGNMENT.

B. Return the form completed by your approved medical provider to your WC Coordinator within 24 hours or the next business day after each doctor’s visit.




7. If your doctor does not release you immediately to return to work with or without

restrictions you must: A. Maintain regular contact with you agency/supervisor and keep them advised

of your return to work status. B. Maintain contact with the WC Coordinator and provide all requested

documentation. C. The WC Coordinator will provide you with a Notice of Intent for Lost Time

Payment form. You have the right to place your leave balances on hold and receive temporary total disability benefits or to forego these benefits and utilize your accrued leave balances. You must make a selection and return the form to Human Resources within seven calendar days of your first day of absence. Failure to do so will result in the use of your accrued leave balances.

D. Provide the TDOC Human Resources office with your current address and active phone number at all times.

8. When your medical provider releases you to return to work with or without restrictions you must notify your WC Coordinator within twenty-four (24) hours or the next business day.

A. If you are not able to return to full-duty in your regular job, a temporary modified or transitional duty assignment will be offered; provided we can accommodate your limitations. You will receive regular wages and benefits during this temporary assignment. The assignment will last up to 180 days as medically necessary and determined by your approved medical provider. You must comply with the following rules:

1. If requested you must provide the Safety Management Team with your work history and an inventory of your skills and abilities to assist with the development of your temporary task elements.

2. Cooperate with and participate in the investigation of your claim, your medical treatment plan, and your defined modified or transitional assignment.

3. Once offered a temporary work assignment you do not have the right to refuse such assignment. Failure to accept a modified or transitional assignment may prohibit you from collecting Temporary Total Disability benefits and can result in disciplinary action up to and including separation for the Good of the Service.

4. If you feel you are medically unable to participate in a temporary modified or transitional assignment the WC Coordinator may contact the TPA to request a re-evaluation with an approved medical provider.

5. Adhere to your medical treatment plan and attend all scheduled appointments. If you are unable to schedule medical appointments outside working hours, you must use personal leave for these absences.

6. Follow all TDOC and DOHR Rules and polices as they relate to performance and conduct, to include following standard procedures for reporting absences from work. Failure to do so may result in disciplinary action.




9. You have a right to seek medical treatment and file a Worker’s Compensation Claim

for occupational injuries or death in the line of duty within one year of the date of occurrence. You must report any incident to your supervisor or WC Coordinator within twenty-four hours of the incident.

10. You have the right to know the status of your claim; contact your Worker’s Compensation Coordinator if you have questions concerning:

A. The status of your claim; B. Your leave balances or payroll; C. Available network providers;

D. Filling a prescription from your approved worker’s compensation provider, (Follow the instructions of the third party administrator relative to your pharmacy benefits and utilize an in network provider. Do not fill prescriptions to be billed to your general health insurance carrier.)

E. How to contact your Case Manager; or F. Your employment status. RETAIN THIS DOCUMENT FOR YOUR RECORDS




I HAVE RECEIVED AND READ THE FOLLOWING NOTICES REGARDING WORKERS’ COMPENSATION PROCEDURES AND BENEFITS AND THE DEPARTMENT OF CORRECTION RETURN TO WORK PROGRAM. REMOVED #1 DEPARTMENT OF TREASURY FORM

1. Department of Correction Policy 303.04 Workers’ Compensation Claims and

Return to Work Program.

2. CR-3875 TDOC Notice of Employee Rights and Responsibilities in the Event of a Workplace Incident

Print Name

Signature

Date

Human Resources Representative

Please sign this page and return to instructor. Keep the other information for your future reference. COPY TO EMPLOYEE ORIGINAL IN EMPLOYEE FILE


WORKERS’ COMPENSATION NOTICE OF RECEIPT OF CLAIM

CR4116(Rev. 04/2019) Duplicate As Needed RDA####

Employee Name: Employee ID:

Work Location: Date of Injury:

The Human Resources Office has received notice that you were involved in an incident which may have resulted in an injury or illness arising out of and in the course of your employment. Your injury was reported to the State of Tennessee’s third party administrator, CorVel Claims Management by you and/or your supervisor or Human Resources staff. CorVel will review relevant information and make a determination if the incident is a compensable claim and they will approve or deny the request.

In the event of an Assault Injury Claim you and your supervisor shall complete, sign and submit form TR-0231, Accident Report, in addition to any additional information/applicable forms, to Worker’s Comp (WC) Coordinator. You are required to submit any and all updated medical status reports you receive from your approved medical provider(s), to your local WC Coordinator within one business day of receipt.

If your approved medical provider, in the course of treating your compensable injury, determines that you are temporarily unable to return to perform any work, then you may be eligible for temporary total disability benefits. You may elect to be placed in a without pay status and be paid lost time wages. You may choose to use your accumulated sick, compensatory, and annual leave instead of or prior to requesting temporary total disability benefits. You must submit a completed Notice of Intent for Lost Time Benefits (enclosed) to your local Human Resources Office within seven calendar days of your first day of absence. Failure to submit the Notice of Intent election form will result in the use of your accrued leave balances.

If your approved medical provider releases you to return to work with or without limitations/restrictions you should provide the work status report to the local WC Coordinator immediately upon receipt and be prepared to return to duty. If you are able to perform the essential functions of your job you will return to your pre-injury position. Limitations or restrictions may prohibit you from performing some functions of your position and you will be placed in a modified duty assignment; this should be discussed with you and communicated to your supervisor.

If you are unable to perform the essential job functions of your pre-injury position, you will be placed on transitional duty; provided a job is available within your limitations/restrictions and physical abilities. You will receive regular wages and benefits during this temporary assignment. Review TDOC Policy 303.04 Worker’s Compensation Claims and Return to Work Program. You will be required to:

Cooperate with and participate in investigation of your claim, your medical treatment plan, and a defined modified or transitional duty assignment.

In the event you are unable to work, you must maintain weekly contact with your supervisor and ensure your WC Coordinator is informed of your return-to-work status.

Submit any and all updated medical status reports to your local WC Coordinator immediately upon receipt within one business day.

Adhere to your medical treatment plan and attend all scheduled appointments.

Received by: Date:

Or mailed certified to:

Humans Resources Representative: Date:

Enclosed: Workers’ Compensation Medical Release or Work Status Report Notice of Intent for Lost Time Benefit


NOTICE OF INTENT FOR LOST TIME PAYMENT

CR4092(Rev.03‐18) RDA####

If your approved medical provider, in the course of treating your compensable injury, determines that you are temporarily unable to return to perform any work, then you are eligible for temporary total disability benefits. These benefits, are also called lost time pay, are intended to replace part of the income you may lose as a result of your compensable injury. To receive temporary total disability benefits, you must be on a leave without pay status from your employer during the time you wish to receive the temporary total disability benefits. You may choose to use your accumulated sick and annual leave instead of or prior to requesting temporary total disability benefits since workers’ compensation benefits will be less than the amount you would receive if you use your sick, compensatory or annual leave. This is a choice to be made by you, the employee. To qualify for temporary total disability benefits, you must be out of work due to your compensable injury for seven days. Your temporary total disability benefits would then begin to accrue on the eighth day of disability. If you are out of work for 14 days or more, then you are eligible to receive temporary total disability benefits for the full period of disability. The amount of temporary total disability benefits you receive is equal to 66 and 2/3 percent of your average weekly wage at the time of your accident. You must submit this completed Notice of Intent for Lost Time Benefit to your local Human Resources Office within seven calendar days of your first day of absence. Failure to return this form will result in the use of your accumulated leave balances.

I, , Empl ID #: have been advised by my Human Resource Office that I have the right to apply for the lost time payment of total temporary disability (TTD) related to my Worker’s Compensation Claim or I may elect to use my accrued leave balance in lieu of TTD benefits.

MAKE YOUR SELECTION BELOW

I agree to place all of my accumulated leave on hold and receive temporary total disability (TTD) benefits during my absence. I understand that I must be in a leave without pay status for seven days before lost time pay will take effect and the amount of the pay will be 66 2/3 % percent of my weekly wage at the time of the incident.

I agree to forego the above mentioned benefit and choose to use my accumulated sick, annual, and compensatory leave. I realize that by taking this action I will not be eligible to receive TTD lost time pay during the time that I am on paid leave.

Employee Print Name:

Employee Signature: Date:

Human Resource Office Use Only

Received By: Date Received: Claim #: Date of Injury: Date TTD Started: Date TTD Ended: Date ePAF PLA: Date EPAF RFL: ePAF Transaction #: ePAF Transaction #:


WORKERS’ COMPENSATION MEDICAL RELEASE OR WORK STATUS REPORT

CR3873(Rev. 09-17) Duplicate As Needed RDA####

EMPLOYEE: Give this form to your approved medical provider to complete the Physician section below:

HUMAN RESOURCES/SUPERVISOR COMPLETE THIS SECTION:

Employee Name: Empl ID: Date of Injury: Claim #: Work Location:

PHYSICIAN: Please return to the following Human Resources Staff

Name: E-Mail: Work Location: Fax:

PHYSICIAN: Please complete this section

DIAGNOSIS:

In accordance with this patient’s physical capability please check all that apply:

May resume work immediately, no restrictions. May resume work immediately, with the following restrictions:

Sedentary work only (sitting) hours, Standing/walking hours, Lifting lbs. Range for: Lifting lbs Carrying lbs Pushing lbs Pulling lbs

Restrictions specific to hand/arm injuries:

Left: No use 0% Occasional 1-33% Frequent 34-66% Constant 67-100% Right: No use 0% Occasional 1-33% Frequent 34-66% Constant 67-100% Other Restrictions:

Restrictions specific to lower body hip/knee/leg/foot injuries:

Left: No use 0% Occasional 1-33% Frequent 34-66% Constant 67-100% Right: No use 0% Occasional 1-33% Frequent 34-66% Constant 67-100% Other Restrictions:

Restrictions specific to the back and torso:

Stooping/ Bending Detail other physical or mental limitations: Frequently 34-66% Occasionally 6-33% Not at all 0-5% Crouch/Crawl/Kneel Frequently 34-66% Occasionally 6-33% Not at all 0-5% Twist/Climb/Balance Frequently 34-66% Occasionally 6-33% Not at all 0-5%

Patient may return to full-duty on date:

Patient is unable to return to work in any capacity at this time.

Follow-up appointment Date: Time:

Physician Name: Phone:

Physician Signature: Date:

CR-3857 Duplicate As Needed RDA 1458


EXPOSURE CONTROL

HEALTHCARE PROVIDER WRITTEN OPINION FOLLOWING EXPOSURE TO BLOODBORNE PATHOGEN(S)

INSTITUTION/DISTRICT/DIVISION

Instructions: To Be Completed by the offsite Community Healthcare Provider The Healthcare Worker’s Written Opinion must be completed and given to the employee within 15 days. Employee Name: Exposure Date: Employee SSN: Date/Time: Supervisor: Site: Tennessee Department of Correction (TDOC) requires the following information regarding the counseling, care and treatment of the above named employee pursuant to the OSHA Occupational Exposure to Bloodborne Pathogens Final Rule. All counseling, testing, and treatment are made in accordance with the current Public Health Service (CDC) guidelines. Please complete this form during the initial visit and instruct your patient (TDOC employee) to return the completed form to Human Resources within three days. A copy of this completed form must be given to the employee within 15 days of the initial evaluation. Provider Initial Treatment and Recommendations for Employee Information concerning the source’s individual’s HIV, HBV, or HCV status must be treated as Confidential. Has the employee been informed of the results of the evaluation? Yes No Date:

By Whom: Has the employee been told about any medical conditions resulting from exposure to blood or other potentially infectious diseases which require further evaluation or treatment? Yes No

By Whom: Was Hepatitis B vaccination indicated, and did employee receive vaccinations? Yes No Recommended Date of Next Healthcare Provider Follow-Up:

Healthcare Provider Name: Phone: Healthcare Provider Address: Healthcare Provider Signature: Date:

CR-3856 Duplicate As Needed RDA 1458


EXPOSURE CONTROL

MEDICAL WRITTEN AUTHORIZATION LEAVE/RETURN TO WORK FOLLOWING EXPOSURE TO BLOODBORNE PATHOGEN(S)


To Be Completed By Medical Healthcare Provider After treatment the employee must return this completed form to the Institution/District/Central Office Worker’s Compensation Coordinator prior to returning to work. Employee Name: Employee SSN: Date of Injury: Nature of Injury:

Provider Name: Address: Phone: Fax: First Visit Date: Follow-Up Visit Date: Please Check One: Employee may return to work with no restrictions . Employee may return to work with the following restrictions (specify)

Employee may not return to work for the following reason:

Authorized Signature: Title: Date:

CR-3503 (Rev. 03-14) Duplicate as Needed RDA 1458


EXPOSURE CONTROL TRAINING

POST EXPOSURE INCIDENT EVALUATION


EMPLOYEE NAME: POSITION:

OCCURRENCE DATE/TIME: REPORTED DATE/TIME:

EMPLOYEE’S REPORTED DESCRIPTION OF THE EXPOSURE:

IN RELATION TO THIS EXPOSURE, ENGINEERING CONTROLS IN PLACE AT THIS TIME WERE:

Adequate Inadequate If inadequate, explain:

IN RELATION TO THIS EXPOSURE, WORK PRACTICE IN PLACE AT THIS TIME WERE:


IN RELATION TO THIS EXPOSURE, SHARPS INJURY PREVENTION DEVICES WERE:


IN RELATION TO THIS EXPOSURE, PERSONAL PROTECTIVE EQUIPMENT IN PLACE AT THIS TIME WERE:


EVALUATE CAUSE OF EXPOSURE: Lack of resource (policy, equipment, control) Lack of employee knowledge (procedures, policies) Failure to follow procedures or policies Cause beyond Employer/Employee Control (example: uncooperative patient) Other (Explain)

RECOMMENDATIONS TO PREVENT FUTURE EXPOSURE:

Full Legal Signature of Infection Control Representative Date

TENNESSEE DEPARTMENT OF CORRECTION TASK INVENTORY FOR MODIFIED/TRANSITIONAL DUTY ASSIGNMENT

CR3876 (REV. 02.20) Duplicate as Necessary S1280

Please Print

Employee: Supervisor: Work Location:

Transitional Duty Task

1. TASK: Physical Requirements:






Modified Duty- Employee may perform all pre-injury task except those listed below:

1. TASK: 2. TASK: 3. TASK:

This is a temporary modified duty or transitional duty (TD) assignment the duration is determined by my medical need but not to exceed one-hundred-eighty (180) days. If I am not released without restrictions at the end of the 180 day period the Safety Management Team will evaluate and determine if additional time may be granted. I am aware that I must adhere to my medical restrictions and limitations as established by my approved treating physician. I shall report any and all changes in my medical restrictions/limitations to my supervisor and the Worker’s Compensation (WC) Coordinator in Human Resources. I shall provide all work status reports to WC Coordinator immediately after receipt from my approved medical provider(s). My temporary duty (TD) assignment will be evaluated every thirty (30) days or as necessary. Additional duties will be assigned as my restrictions/limitations are modified. I am expected to follow all TDOC and DOHR rules and policies as they relate to job performance and conduct; failure to do so may result in disciplinary action. This includes following standard procedures for reporting absences from work.

Employee Signature: Date:

In supervision of an employee on a TD assignment I am not to require, request, or allow the employee to perform duties outside of their defined restrictions and medical limitations. I am to require the employee to work safely and within their physical capabilities. I am to encourage the employee to adhere to their medical treatment plan and arrange schedules as necessary for the employee to attend all scheduled medical appointments.

Supervisor Signature: Date:

Approval: TDOC Site Manager

Approver’s Signature: Date:

Page 1 of 2

TENNESSEE DEPARTMENT OF CORRECTION TASK INVENTORY FOR MODIFIED/TRANSITIONAL DUTY ASSIGNMENT

CR3876 (REV. 02.20) Duplicate as Necessary S1280

RESTRICTIONS AND LIMITATIONS NOTICE TO SUPERVISOR

Please Print

Title:

Date Restrictions Begin: ________ Follow-up Date: ___

1. Restriction:

2. Restriction:

3. Restriction:

4. Restriction:

5. Restriction:

6. Restriction:

7. Restriction:

8. Restriction:

I am aware the above listed restrictions and limitations were given to me by my approved treating physician and subsequently provided to TDOC's human resources staff. I must adhere to my medical plan, restrictions, and limitations as established by my approved treating physician. Employee Signature: _________________________________________ Date: _ __________________ I have been made aware of the above listed restrictions and limitations for the named employee temporarily assigned to my supervision. I will not require, request, or allow the employee to perform duties outside of his/her defined restrictions and medical limitations. Supervisor Signature: _________________________________________ Date: _ __________________ Original: WC Coordinator

Copy: Employee

Copy: Supervisor

Page 2 of 2

Employee (full name): Supervisor (full name): TDOC Work Location:

CR-3508 (Rev. 03-14) Duplicate as Needed RDA 1458


EXPOSURE CONTROL

OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGEN FOLLOW-UP


C O N F I D E N T I A L NAME: DATE OF OCCURRENCE:

POSITION: TIME OF OCCURRENCE:

REPORTED DESCRIPTION OF THE EXPOSURE (INCLUDE CIRCUMSTANCES AND ROUTE OF EXPOSURE):

CONTACT SOURCE INFORMATION

Contact Source: Known Unknown

Contact source laboratory test results:

HBV HCV HIV Other:

STAFF INFORMATION

Hepatitis B Vaccine status:

Has not been vaccinated

Has been vaccinated Date Series Completed:

Serum Antibody Titer: Date: Results:

PEPline Guidance Obtained: 1-888-448-4911 Hours: 8:00 AM – 1:00 AMCST (9:00 AM – 2:00 AM EST)

Yes Date: Time:

No

PEPline Determined Bloodborne Pathogen Exposure: Referred to ER/Urgent Care

Yes Yes

No No

Staff Refused Treatment Refusal Signed: Yes No

Signature of Reporting Official Date

1. Complete form 2. Send copy with staff for off-site evaluation for Bloodborne Pathogen Exposure 3. Original form to Human Resources Confidential Medical File

CR-3858 Duplicate as Needed RDA 1458


EXPOSURE CONTROL TRAINING

INFORMED REFUSAL OF MEDICAL EVALUATION FOLLOWING EXPOSURE TO BLOODBORNE PATHOGEN (S)

Declination of Treatment: I understand that I have been exposed to blood or other potentially infectious materials and I may be at risk of acquiring Human Immunodeficiency virus (HIV), Hepatitis B virus (HBV) infection and /or Hepatitis C virus (HCV) infection and other bloodborne diseases. My employer has offered to provide follow-up medical care and evaluation for me in order to ensure that I have full knowledge of whether I have been exposed to or contracted an infectious disease from this incident. I understand that the evaluation is at no charge to me. I decline the opportunity for evaluation at this time. I understand that by declining an evaluation, I continue to be at risk of acquiring a bloodborne disease. If in the future I want to be evaluated; I can receive an evaluation at no charge to me. Name of Exposed (Print): Date: Signature of Exposed: Witness Name (Print): Date:

Witness Signature/Title:

Documents

Index #: 303.04 Page 1 of 19 ADMINISTRATIVE POLICIES AND