PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH

PHILADELPHIA DEPARTMENT

OF PUBLIC HEALTH

Injury On Duty And

Workers’ Compensation

Incident Investigation Packet

Rev. 4/2007 1 of 28

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TABLE OF CONTENTS

1. Accident, Injury, and Illness Investigation and Reporting Policy 2. Supervisor Injury on Duty and Incident Investigation Checklist 3. Supervisor Injury on Duty Instruction Sheet

4. Instruction Sheet - City of Philadelphia Accident, Injury, and Illness (COPA II)

Report

5. City of Philadelphia Accident, Injury, and Illness (COPA II) Report (Form 82-S-58)

6. Medical Care Provider Referral Authorization and Employee Notification (Form 82-S-30) 7. City of Philadelphia Bloodborne Pathogens Exposure Report Form

8. Motor Vehicle Related Injury Supplemental Forms:

a. Traffic Accident Report – City Vehicle (Form 82-S-87) b. Personal Auto Program – Traffic Accident Report Form c. Shared Vehicle Claim Forms (Risk Management)

9. City of Philadelphia – Medical Care Provider Panel and Occupational Clinic

Assignment by Work Zip Codes

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POLICY: ACCIDENT INVESTIGATION POLICY Rev. 3/2011

City of Philadelphia Department of Public Health

Safety and Health Policy and Program

POLICY: ACCIDENT INJURY AND ILLNESS INVESTIGATION AND

REPORTING POLICY The Department is bound by Civil Service Regulation 32: Injury and Disability and PA Workers’ Compensation Act to provide workplace injury benefits to all civil service employees. The Department makes every effort to ensure all incidents are investigated and corrective actions implemented to mitigate future occurrences. In order to achieve this gal, the department requires that employees report all incidents (including near misses) to their supervisor or manager regardless of severity or whether or not an injury occurred immediately, but no later than 24-hours of the incident. When an injury occurs, it is the manager’s or supervisor’s responsibility to document and report the injury by completing a City of Philadelphia Accident Injury and Illness report form (82-S-58A) as soon as possible, but no later than within 48 hours of the report injury. All related forms pertaining to the injury must also be completed and forwarded to the Department Safety Unit. The following information provides specific information regarding protocols and procedures for reporting, investigating, treating, and correcting workplace safety related incidents.

• Department of Public Health and Department of Behavioral Health / Intellectual Disability Services Supervisor and Manager Injury on Duty and Workers’ Compensation Incident Investigation Program

• City of Philadelphia Civil Service Regulations 32

SUPERVISOR & MANAGER INJURY ON DUTY AND INCIDENT

CHECKLIST Ensure all items have been completed to provide the injured employee(s) proper medical

services from the City’s Comp Clinic (network of approved medical providers). CHECK WHEN COMPLETED

Read and Review with employee “Injured on Duty Instruction Sheet”

Complete COPA II Report form - Both Sides with employee present o Ensure PART V: Fundamental Causes and Corrective Action section is

completed. For Bloodborne Pathogens Exposure Incidents - In Addition to the COPA II Report

form, complete the City of Philadelphia Bloodborne Pathogens Exposure Report Form.

Ensure ALL SIGNATURES are obtained. Review ASSIGNED COMP CLINIC SITES list to find the assigned comp clinic for

specific office worksite by ZIP CODE o **NOTE** For Bloodborne Pathogens Incidents/Injuries, Employee MUST

be referred ONLY to either: Jeanes Hospital - Business Health Clinic Hahnemann University - Worknet Occupational Clinic

Supervisor is responsible for completing the: o Medical Care Provider Authorization Referral and Employee Notification

form (Form 82-S-30 - Rev. 8/2010) o Retain a copy, provide original to employee to take to comp clinic for medical

services. Service will not be provided without a signed referral form. **NOTE**ALL incidents reported more than 24 hours after the incident occurred MUST be referred by Personnel Employee Safety Unit, NOT the supervisor.

Call in the incident and obtain claim # - notated on top of COPA II CompServices Inc. 1717 Arch St, 14th Floor Ph: (866) 463-2524 Fx: (215) 587-1270 Philadelphia, PA 19103

Fax ALL completed forms to Third Party Administrator at FAX: (215) 587-1270. For motor vehicle crash related incidents; Employee MUST complete the proper form:

See IOD Packet for correct form. Immediately NOTIFY and fax ALL FORMS to Safety Unit. FAX: (215) 685-5212

I have reviewed and completed all of the items listed above SUPERVISOR SIGNATURE:____________________________________ DATE:________

Rev. 04/2007

PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH

Supervisor Injury On Duty

Instruction Sheet

INSTRUCTIONS A. City Provider Panel for IOD Treatment Refer to EPO Occupational Health Clinic and Hospital Service Zip Code Distribution list. City worksites are assigned to specific occupational health clinics or hospitals for IOD incidents by the worksite zip code. Employees are to be referred to the assigned site unless the work-related injury or illness is an emergency. For emergencies, proceed to the nearest Emergency Room. After treatment, employees receive a City of Philadelphia Encounter Form. To receive Injury Time (“I” time) promptly Provide copies of the Encounter Form to the following:

1. Employee’s supervisor 2. Personnel Employee Safety Unit: Fax# (215) 685-5212.

B. Emergency Room Treatment: After treatment at the nearest Emergency Room, employees are to be seen at the designated occupational health clinic or hospital the NEXT BUSINESS DAY for treatment and duty status. Copies of all Emergency room paper work must be provided to the clinic for proper follow up treatment/evaluation. Copies of Emergency Room release paperwork must be submitted to the Safety Unit C. Follow Up Treatments

1. City of Philadelphia Encounter Form COPIES must be provided to SAFETY UNIT for all appointments related to the injury.

2. A doctor’s note is REQUIRED FOR ALL RELATED TREATMENTS such as: Physical therapy Specialists (orthopedist, podiatrist, dermatologist etc.) X-rays

3. To accurately grant “I” time, the doctor’s note MUST INCLUDE the following: Date Time (ARRIVAL, DEPARTURE)

COPIES of the Doctor’s note must be provided to the SAFETY UNIT for all appointments related to the injury. C. Employee Responsibility For Reporting Duty Status It is the employee’s responsibility to notify his/her supervisor and the Safety Unit of the employee’s duty status and/or restrictions. This notification should be done ASAP upon the completion of the clinic appointment.

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Rev. 04/2007

D. Time Recording Employees MUST RECORD leave (out) and return (in) times on time sheets for all appointment regarding the injury. Employees are required to report to work prior to and after appointments. Exceptions include appointments that are within a half (1/2) hour of his/her start/leave time, employees are not required to report to the work site. Questions concerning this matter should be addressed to the Safety Unit. E. Absences“I” time is granted ONLY when documented by a City of Philadelphia Encounter Form or doctor’s note on letterhead is provided. Absences not verified by the City’s Comp Clinic will be charged to the employee’s accrued time and be considered in violation with Civil Service Regulation 32.

F. Treatment Compliance To remain eligible for Civil Service Regulation 32 benefits employees must treat EXCLUSIVELY within the City’s health care provider network (as provided on the EPO Occupational Clinic & Hospital Service Zip Code Distribution list) AND follow the provider’s instructions. If for any reason an employee cannot report to work as instructed on the Encounter Form provided by the clinic, The Safety Unit needs to be contacted in order to refer the employee back to the clinic for revaluation.

ONLY the primary care doctor at the City’s Comp Clinic can determine the employee’s DUTY STATUS. G. RequirementsIf an employee suffers a work related injury, he/she is required to treat with one of the health care providers listed on City’s network providers and to continue to treat with them for a at least ninety (90) days from date of FIRST VISIT.

The City will not be responsible for payment of unauthorized treatment with a physician or health care provider other than the City’s network providers.

After the 90-day period, employees considering treatment outside the City’s network MUST NOTIFY the Safety Unit IN WRITING of intent to treat out of network. Out of network treatment no longer entitles employees to benefits under Regulation 32. A NO DUTY status determination by an out of network provider requires the employee to take an unpaid Family and Medical Leave of Absence (FMLA). H. QuestionsQuestions or concerns regarding workers’ compensation and/or Civil Service Regulation 32 benefits or the adequacy of medical care, please call the Employee Safety Unit at (215) 685-5205.

**NOTE** I.O.D. TIME IS CONTINGENT UPON RECEIPT OF ENCOUNTER FORMS OR DOCTOR NOTES WITH THE ABOVE SPECIFIED INFORMATION.

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INSTRUCTION SHEET FOR THECITY OF PHILADELPHIA ACCIDENT, INJURY & ILLNESS (COPA II) REPORT

COMPLETE ALL SECTIONS OF THIS REPORT. FORMS WITH MISSING OR INCOMPLETE INFORMATION WILL BE RETURNED.

IT IS RECOMMENDED THAT THE SUPERVISOR AND INJURED EMPLOYEE COMPLETE THIS FORM JOINTLY. HOWEVER, THE SUPERVISOR IS ULTIMATELY RESPONSIBLE FOR THE COMPLETION OF THIS FORM.

1. Name: Enter employee’s last name, first name and middle initial (if applicable).2. Present Address: Enter employee’s most current address3. Occurrence Type: Select one of the three options - Injury in the event medical treatment or first aid has been provided due to an instan-

taneous event; Illness in the event medical treatment or first aid has been provided due to repeated exposure; or Near-Miss if no injury or illness occurred, but hazardous conditions existed that could have caused an injury or illness.

4. Gender: Select male or female.5. Employee Phone Numbers: List employee’s home, work, and/or cell numbers.6. Department & Division: Enter employee’s department and division.7. Normal Unit/District: Enter employee’s normal unit and/or district.8. Payroll No.: Enter employee’s payroll number.9. Work Status: Select one of the four options - Full-Time, Part-Time, Seasonal or Temporary.10. Current Job Title: Enter employee’s current job title.11. Job Title at Time of Injury: Enter the job being performed by the employee at the time of the injury/illness.12. Work Assignment: Select one of the three options - Routine, Non-Routine (either "out of job class" or "not everyday job"), or Emergency.13. Immediate Supervisor & Phone Number: Enter the employee's regular supervisor and their phone number.14. Immediate Supervisor on Duty at Time of Injury: Enter the supervisor on duty at the time of the injury.15. Witnesses: List the witness’ last name, first name and middle initial (if applicable), telephone number, and job title if employed by the City

of Philadelphia. Use additional sheets if needed.16. Date of Injury: Enter the date of injury in MM/DD/YYYY format.17. Time of Injury: List the exact time of the injury and then select AM or PM.18. Date Injury Reported: Enter the date the injury was reported by the employee to the appropriate supervisor, using MM/DD/YYYY format.19. Time Injury Reported: List the exact time that the injury was reported and then select AM or PM.20. Usual/Normal Work Hours?: Check yes if the injury occurred during the employee's usual or normal work hours, or check no if not.

Checking yes means that 21 will be checked no, and vice versa.21. Overtime Shift?: Check yes if the injury occurred during overtime, or check no if not.22. Straight Shift?: Check yes if the injury occurred during a straight shift, or check no if not. Checking yes means that 23 will be checked

no, and vice versa.23. Rotating Shift?: Check yes if the injury occurred during a rotating shift, or check no if not.24. Injury Occurred INSIDE: Check only if the injury/illness occurred inside a building or facility. If injury occurred inside, complete 25-26.

If injury occurred outside, skip to 27.25. Address & Building Name: List compete street address with city, state and zip code.26. Exact Location: List the floor (2nd, 3rd, etc.) and work area; be specific.27. Injury Occurred OUTSIDE: Check only if the illness/injury occurred outside - on the street, in a yard, park, etc. If injury occurred out-

side, complete 28-29. If injury occurred inside, skip to 30.28. Location - Intersection: Enter the exact intersection where the injury/illness occurred. If the injury/illness did not occur at an exact

intersection, list the nearest intersection instead. Then, estimate the # of feet and the direction (north, south, east or west) from that intersection.

29. Outside Normal Work Area/District?: Check yes if the incident occurred outside the employee’s normal work area or district, and then enter the area/district in which the incident occurred. Check no if the incident occurred within the employee’s normal geographic work area or district.

30. Accident Type: Check only one box, or check other and enter the type of accident.31. Body Part(s) Injured: Check the body part(s) injured. For each body part checked, specify front (F) and/or back (B) and left (L) and/or

right (R) in the adjacent fields.32. Describe Exactly What Happened: Describe the incident in detail. List all equipment, materials, etc. Use additional sheets if needed.33. Medical Treatment & Initial Treatment Date: Select only one of the four options. If First Aid, specify date and type of first aid adminis-

tered (plastic bandage, ice pack, etc.). If City Medical Provider or Other, specify date and site.34. D.C. Number: If applicable, fill in the D.C. number from the traffic accident form.35. A.I.D. Number: If applicable, fill in the A.I.D. case number from the traffic accident form.36. Vehicle Property No.: If applicable, fill in the vehicle property number from the traffic accident form.37. Employee Signature: Employee signs here.38. Date: Enter date in MM/DD/YYYY format.39. Immediate Supervisor on Duty Signature: Immediate supervisor on duty at time of injury signs here.40. Date: Enter date in MM/DD/YYYY format.41. Unit Supervisor Signature: Unit supervisor signs here.42. Date: Enter date in MM/DD/YYYY format.43. Dept. Safety Officer Representative Signature: Dept. safety officer representative signs here.44. Date: Enter date in MM/DD/YYYY format.45. For D.C. 47 Employees Only: Initialing and dating here permits release of report information to the Health and Safety Office of D.C. 47.46. Fundamental Causes: To be completed by immediate supervisor on duty at time of injury. Discuss equipment, environment, people and

personal protective equipment (PPE) conditions that may have been present and / or that may have contributed to the injury/illness with the affected employee and any witnesses. Review items A-Y and check ALL that apply.

47. Corrective Actions: To be completed by the Immediate or Unit Supervisor. Talk with the injured employee and any witnesses about the appropriate corrective actions associated with each checked condition in section 46. List them in section 51. Please be specific; for example, list a specific piece of equipment, specific safety procedures, and/or specific PPE.

48. Date Recommendations Implemented: List the date that the recommended corrective actions were implemented in MM/DD/YYYY for-mat. This date can be forwarded to the Departmental Safety Office after corrective actions are completed, if not done at the time the report was submitted.

SIGNING THIS FORM DOES NOT CONFIRM OR ACKNOWLEDGE AGREEMENT WITH THE INFORMATION LISTED ON THE FORM. SIGNING THE FORM CONFIRMS THAT EVERYONE IS AWARE THAT THE REPORT HAS BEEN COMPLETED PER ITS INSTRUCTIONS.

A SPECIAL NOTE ABOUT ADOBE ACROBAT READER: Users with the free Adobe Reader will be unable to save the completed form to their computer’s hard drive. Upon completing the editable portions of this form, users unable to save should print

an additional hard copy of the completed form to save for their records.

FORM 82-S-58A (REV. 12/2004)9 of 28

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COPA II (CITY OF PHILADELPHIA ACCIDENT, INJURY & ILLNESS) REPORTImmediate Supervisor MUST Complete This Form

1. NAME (LAST, FIRST, M.I.) 2. PRESENT HOME ADDRESS

3. OCCURRENCE TYPE 4. GENDER 5. EMPLOYEE PHONE NUMBERS (HOME [H], WORK [W], CELL [C])

6. DEPARTMENT & DIVISION 7. NORMAL UNIT / DISTRICT 8. PAYROLL NO.

9. WORK STATUS 11. JOB TITLE AT TIME OF INJURY10. CURRENT JOB TITLE & START DATE

12. WORK ASSIGNMENT 14. IMMEDIATE SUPERVISOR ON DUTY AT TIME OF INJURY13. CURRENT IMMEDIATE SUPERVISOR & PHONE NUMBER

15. WITNESSES NAME (LAST, FIRST, M.I.) PHONE NUMBER JOB TITLE (IF APPLICABLE)

WITNESS #1

WITNESS #2

16. DATE OF INJURY 17. TIME OF INJURY 18. DATE INJURY REPORTED 19. TIME INJURY REPORTED

20. USUAL/NORMAL WORK HOURS? 21. OVER TIME SHIFT? 22. STRAIGHT SHIFT? 23. ROTATING SHIFT?

24. INJURY OCCURRED:

INSIDE (CHECK BOX & COMPLETE 24-25)

OUTSIDE (CHECK BOX & COMPLETE 26-27)

25. BUILDING NAME & ADDRESS 26. EXACT LOCATION (FLOOR, AREA, ETC.)

27. LOCATION - INTERSECTION & DIRECTION (N / S / E / W) 28. OUTSIDE NORMAL WORK AREA / DISTRICT?

29. ACCIDENT TYPE (PLEASE CHECK ONLY THE MOST APPROPRIATE ACCIDENT TYPE OR SPECIFY) 30. BODY PART(S) INJURED (SPECIFY FRONT[F] OR BACK[B] / LEFT[L] OR RIGHT [R])

OVEREXERTION (LIFTING, CARRYING)

FALL (SAME LEVEL)

FALL (DIFFERENT LEVEL)

STRUCK BY/AGAINST OBJECT, EQUIPMENT

MOTOR VEHICLE ACCIDENT/CRASH

(COMPLETE PART III & CRASH FORM)

CAUGHT BETWEEN/UNDER/IN/ON

INHALATION/ABSORPTION/INGESTION OF

CHEMICAL, BIOLOGICAL

PHYSICAL AGENT (NOISE, RADIATION)

CONTACT WITH/BY EXTREME TEMPERATURE

ASSAULTED BY ANOTHER PERSON

ELECTRIC SHOCK

OTHER (SPECIFY) _____________________

HEAD/FACE

EYE(S)

HAND(S)/FINGER(S)

CHEST

LEG(S)

SHOULDER

KNEE

OTHER ________________________

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

NECK

UPPER BACK

LOWER BACK

ARM(S)

STOMACH

FEET/TOE(S)

WRIST(S)

OTHER

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

_____ / _____

31. DESCRIBE EXACTLY WHAT HAPPENED (TALK WITH EMPLOYEE TO UNDERSTAND AND DESCRIBE THE ACTIONS OF THE EMPLOYEE AT THE TIME OF INJURY, THE TYPE OF ACCIDENT, HOW THE INJURYWAS SUSTAINED, THE SPECIFIC BODY PARTS INJURED, AND ANY INVOLVEMENT WITH/FROM OTHER INDIVIDUALS CONTRIBUTING TO THE INJURY. USE ADDITIONAL SHEETS IF NECESSARY.)

32. MEDICAL TREATMENT & INITIAL TREATMENT DATE (CHECK ONE & WRITE IN DATE)

NONE FIRST AID _________ CITY MEDICAL PROVIDER (SPECIFY DATE & SITE) ____________________________________________________________________________________

OTHER (SPECIFY DATE & SITE) _____________________________________________________________________________________________________________________________________

33. D.C. NUMBER 35. VEHICLE PROPERTY NO.34. A.I.D. CASE NUMBER

37. EMPLOYEE SIGNATURE 38. DATE 39. IMMEDIATE SUPERVISOR ON DUTY SIGNATURE 40. DATE

41. UNIT SUPERVISOR SIGNATURE 42. DATE 43. DEPT. SAFETY OFFICER REPRESENTATIVE SIGNATURE 44. DATE

45. FOR D.C. 47 EMPLOYEES ONLY: BY INITIALING AND DATING BELOW, I HEREBY AUTHORIZE THE CITY OF PHILADELPHIA TO RELEASE THIS FORM TO THE HEALTH AND SAFETY OFFICE OF THE D.C. 47 HEALTH AND WELFARE FUND.

EMPLOYEE INITIALS __________ DATE __________

FORM 82-S-58 (REV. 12/2004) IMPORTANT - A FALSE STATEMENT CAN RESULT IN DISMISSAL PAGE 1 OF 2

FULL-TIME SEASONALPART-TIME TEMP

ROUTINE NON-ROUTINEEMERGENCY

M FINJURY ILLNESS NEAR-MISS

AMPM

AMPM

YES NO YES NO YES NO YES NO

YES (SPECIFY DISTRICT) _____________ NO

INJURY OCCURRED:

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PART IV SIGNATURES

PART III MOTOR VEHICLE ACCIDENT/CRASH (NOTE: TRAFFIC ACCIDENT - CITY VEHICLE FORM MUST ALSO BE COMPLETED)

PART II DESCRIPTION

PART I IDENTIFICATION

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COPA II (CITY OF PHILADELPHIA ACCIDENT, INJURY & ILLNESS) REPORTImmediate Supervisor MUST Complete This Form

46. THE IMMEDIATE SUPERVISOR ON DUTY SHALL CHECK ALL THAT APPLY

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B.

C.

D.

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F.

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I.

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Y.

CONDITIONS POSSIBLE CORRECTIVE ACTIONS

A DEFECT IN EQUIPMENT, TOOLS, OR MATERIALS CONTRIBUTED TO THEHAZARDOUS CONDITION.

AN EQUIPMENT INSPECTION PROCEDURE WAS NOT IN PLACE TO DETECTTHE HAZARDOUS CONDITION.

THE CORRECT EQUIPMENT, TOOLS, OR MATERIALS WERE NOT USED ORWERE NOT READILY AVAILABLE.

SUBSTITUTE EQUIPMENT, TOOLS, OR MATERIALS WERE USED IN PLACE OFCORRECT ONES.

THE DESIGN OF THE EQUIPMENT, TOOLS, OR MATERIALS CONTRIBUTED TOTHE HAZARDOUS CONDITION OR CREATED OPERATOR ERROR.

OTHER EQUIPMENT FACTORS NOT LISTED ABOVE CONTRIBUTED TO HAZ-ARDOUS CONDITION (NO GUARDING, WEIGHT/SIZE EQUIPMENT, ERGONOMICS).

THE LOCATION/POSITION OF EQUIPMENT/MATERIAL/EMPLOYEE CON-TRIBUTED TO THE HAZARDOUS CONDITION.

EMPLOYEE SHOULD NOT HAVE BEEN IN THE VICINITY OF THE EQUIP-MENT/MATERIAL OR THERE WAS NOT SUFFICIENT WORKSPACE.

ENVIRONMENTAL CONDITIONS SUCH AS NOISE LEVELS, ILLUMINATION,VENTILATION, VIBRATION, TEMPERATURE EXTREMES, OR RADIATION WEREA CONTRIBUTING FACTOR.

OTHER ENVIRONMENTAL FACTORS NOT LISTED ABOVE CONTRIBUTED TO AHAZARDOUS CONDITION (WEATHER, EROSION, DECAY OF METAL).

THERE ARE NO WRITTEN OR KNOWN PROCEDURES OR RULES FOR THISJOB.

WORK PROCEDURES IN PLACE DID NOT ANTICIPATE OR DETECT THE FAC-TORS THAT CONTRIBUTED TO THE INCIDENT.

NO ONE DETECTED, ANTICIPATED, OR REPORTED A HAZARDOUS CONDITION.

THERE WAS A FAILURE TO DETECT OR CORRECT DEVIATIONS FROM JOBPROCEDURE.

EMPLOYEE DID NOT KNOW THE JOB PROCEDURE OR THE EMPLOYEE DEVIATED FROM KNOWN JOB INSTRUCTIONS.

O.

THERE WAS A LACK OF SKILL OR KNOWLEDGE FOR THIS WORK ACTIVITY.

JOB PROCEDURES WERE TOO DIFFICULT TO PERFORM BECAUSE OF PHYSICAL FACTORS OR THE COMPLEXITY OF THE TASK.

A PREVIOUSLY IDENTIFIED AND/OR REPORTED HAZARD CONTRIBUTED TOTHIS INCIDENT.

INDIVIDUALS WERE NOT ADEQUATELY TRAINED IN ACCIDENT PREVENTIONAND AWARENESS.

INADEQUATE ENGINEERING, MAINTENANCE, OR WORK STANDARDS CONTRIBUTED TO THIS INCIDENT.

NO PERSONAL PROTECTIVE EQUIPMENT (PPE) WAS SPECIFIED OR PROVIDED FOR THE TASK.

EMPLOYEE WAS NOT AWARE OF THE SPECIFIC PPE REQUIRED OR HOW TOMAINTAIN THE PPE.

PPE WAS INADEQUATE OR WAS IMPROPERLY USED WHEN THE INJURYOCCURRED.

EMERGENCY PPE WAS NOT SPECIFIED FOR THIS JOB; EMERGENCY PPEWAS NOT READILY AVAILABLE AND/OR IMPROPERLY USED; THE EMERGENCY PPE DID NOT FUNCTION PROPERLY.

OTHER PPE FACTORS NOT INCLUDED CONTRIBUTED TO THE HAZARDOUSCONDITION (TEARS, RIPS IN PPE, HOT WEATHER).

REVIEW PROCEDURES FOR INSPECTING, REPORTING, MAINTAINING, REPAIRING, AND REPLACING EQUIPMENT, TOOLS, AND/OR MATERIALS USED.

DEVELOP AND IMPLEMENT A PERIODIC INSPECTION PROCESS (DAILY, WEEKLY, ETC.) TO DETECT HAZARDOUSCONDITIONS.

SPECIFY AND PROVIDE CORRECT EQUIPMENT, TOOLS, AND MATERIALS IN JOB PROCEDURES.

PROVIDE CORRECT EQUIPMENT, TOOLS, OR MATERIALS, AND ADVISE AGAINST USE OF SUBSTITUTES IN PLACEOF THE PROPER ONES IDENTIFIED FOR THE JOB PROCEDURE.

REVIEW HUMAN FACTORS AND ENGINEERING PRINCIPLES. ENCOURAGE EMPLOYEES TO REPORT HAZARDOUSCONDITIONS CREATED BY EQUIPMENT DESIGN.

INSTALL/REPLACE GUARDS, AND EVALUATE IF EQUIPMENT SHOULD BE REDESIGNED OR REPLACED.

PERFORM A SAFETY ANALYSIS. CHANGE LOCATION, POSITION, OR LAYOUT OF EQUIPMENT. REPOSITIONEMPLOYEE IF NECESSARY. PROVIDE GUARDRAILS, BARRIERS, WARNING LIGHTS, SIGNS, AND/OR SIGNALS.

REVIEW JOB PROCEDURES, EVALUATE WORKSPACE REQUIREMENTS, AND MODIFY IF REQUIRED.

PERIODICALLY CHECK ENVIRONMENTAL CONDITIONS AS REQUIRED. CHECK RESULTS AGAINST ACCEPTABLELEVELS AND INITATE ACTION FOR THOSE FOUND UNACCEPTABLE.

INSPECT WORK AREA AND PROVIDE PROTECTION AGAINST ENVIRONMENTAL FACTORS.

PERFORM A JOB SAFETY ANALYSIS AND DEVELOP SAFE JOB/STANDARD OPERATING PROCEDURES.

RE-EVALUATE PRESENT JOB PROCEDURES. PERFORM A JOB SAFETY ANALYSIS TO DETERMINE IF A CHANGE INJOB PROCEDURES IS NECESSARY.

IMPROVE EMPLOYEE CAPABILITY IN HAZARD RECOGNITION AND REPORTING. TRAIN ON REMOVING THE HAZARD.

REVIEW SAFETY PROCEDURES. MONITOR JOB PROCEDURES AND CORRECT DEVIATIONS.

IMPROVE JOB INSTRUCTION AND TRAIN EMPLOYEE ON CORRECT PROCEDURE. REVIEW PROCEDURE TO DETERMINE WHY DEVIATION OCCURRED AND MODIFY IF NECESSARY. COUNSEL EMPLOYEE AND PROVIDECLOSER SUPERVISION.

PROVIDE TRAINING/EDUCATION ON WORK ACTIVITY.

CONSIDER CHANGE IN JOB DESIGN AND PROCEDURES.

IMPROVE PROCESS TO CORRECT HAZARDS. ESTABLISH PRIORITIES BASED ON POTENTIAL INJURY SEVERITYAND PROBABILITY. REVIEW RESPONSIBILITY TO INITIATE AND CARRY OUT CORRECTIVE ACTIONS.

TRAIN INDIVIDUALS IN ACCIDENT PREVENTION FUNDAMENTALS.

RE-ENGINEER, START PREVENTIVE MAINTENANCE PROGRAM, OR INSTITUTE BASIC WORK STANDARDS.

REVIEW METHODS TO SPECIFY BOTH PPE REQUIREMENTS AND PROPER PPE DISTRIBUTION AVAILABILITY.

REVIEW JOB INSTRUCTIONS AND PROCEDURES, AS MAINTENANCE OF PPE IS ACCOMPLISHED WITH PROPERSTORAGE AND INSPECTION PRIOR TO USE.

IMPLEMENT PROCEDURES TO MONITOR AND ENFORCE PROPER USE OF PPE. CHECK PPE REQUIREMENTS, STAN-DARDS, SPECIFICATIONS, AND APPROPRIATENESS. TRAIN PERSONNEL ON PPE USE.

PERIODICALLY SELF-INSPECT PPE BEFORE, DURING, AND AFTER USE. ESTABLISH INSPECTION SYSTEM.

IDENTIFY NEED FOR EMERGENCY PPE. PROVIDE AND INSTALL EMERGENCY EQUIPMENT AT APPROPRIATE LOCATIONS. TRAIN ON PROPER USE AND ESTABLISH AN INSPECTION SYSTEM. REPAIR DEFECTS IN EQUIPMENT IMMEDIATELY.

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PART V FUNDAMENTAL CAUSE & CORRECTIVE ACTION

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FORM 82-S-58 (REV. 12/2004) IMPORTANT - A FALSE STATEMENT CAN RESULT IN DISMISSAL PAGE 2 OF 2

47. THE IMMEDIATE/UNIT SUPERVISOR SHALL LIST OR DESCRIBE ALL RECOMMENDED CORRECTIVE ACTIONS: 48. DATE RECOMMENDATIONS IMPLEMENTED

(MM/DD/YYYY) _______/_______/___________

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1. DEPT./DIVISION

2. UNIT 3. PAYROLL NO. CITY OF PHILADELPHIA Blood Borne Pathogen

EXPOSURE REPORT FORM PART I: EMPLOYEE INFORMATION

4. NAME (Last) (First) (M.I.)

5. JOB TITLE

6. HEPATITIS B VACCINE: 1- SERIES COMPLETED (DATE: ___ / ___ / ________ ) 2 – IN PROGRESS (next shot date: ___ / ___ / ________ ) 3- NO

7. IMMEDIATE SUPERVISOR

8. IMMEDIATE SUPERVISOR CONTACT NUMBER (S) ( ) ( )

9. WORK ASSIGNMENT: PLEASE CHECK THE MOST APPROPRIATE CATEGORY

1. ROUTINE / NORMAL 3. NON-ROUTINE / SPECIAL ASSIGNMENT

2. EMERGENCY RESPONSE ASSIGNMENT 4. OTHER ____________________________________________________ SOURCE PATIENT INFORMATION 10. NAME (IF KNOWN) (LAST)

(FIRST)

(M.I.) UNKNOWN

11. EMPLOYEE RELATION 1- CO-WORKER 2- CLIENT

3-PUBLIC / STRANGER

4-DECEASED

5- UNKNOWN

6- OTHER ______________________________________________________________________________

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12. CASE HISTORY INFORMATION OF SOURCE (If Applicable, provide as much information about the source as possible, including known health status, address or phone number)

PART II: DESCRIPTION OF EXPOSURE (Use additional sheets if necessary) 13. EXPOSURE TYPE

1–HANDLING BLOOD/OPIM SPECIMENS 4 - CLEANING BLOOD/OPIM 7 – NEEDLESTICK (Complete Section 13.1)

2- PROVIDING FIRST AID / CPR 5 - SPLASH OF BLOOD/ OPIM 8 – CONTAMINATED SHARP OBJECT (Complete Section 13.1)

3 - HANDLING BIO-HAZARD WASTE 6 – PICK-UP OF HOUSEHOLD TRASH 9 – OTHER (SPECIFY) _____________ __________________________

13.1 FOR NEEDLESTICKS/SHARPS EXPOSURE PROVIDE: MANUFACTURER BRAND OF NEEDLE/SHARP:

MODEL#

SIZE:

14. BODILY FLUID TYPE 1 – HUMAN BLOOD 4- SALIVA ( with visible blood: Yes / No ) 7 - VOMITUS ( with visible blood: Yes / No ) 2 – SEMEN 5 –FECES ( with visible blood: Yes / No ) 3 – VAGINAL SECRETIONS 6 – URINE ( with visible blood: Yes / No ) 15. TREATMENT SITE SENT TO:

1- ER 2 - MEDICAL SITE _______________________________________

16. POST EXPOSURE PROPHYLAXIS (PEP) COUNSELING ; 1- YES 2- NO

MEDICAL SITE: ____________________________________________ DATE:_________________________ TIME: ____________________________

17. DESCRIBE INCIDENT IN DETAIL: WHAT, HOW, WHERE, &WHEN; with DETAILS OF TASKS BEING PERFORMED and INSTRUMENT, FLUID OR MATERIAL INVOLVED (Use back of page if necessary).

18. AMOUNT OF BLOOD/BODILY FLUID, EXPOSURE SITE & DURATION OF CONTACT (Estimate volume of material, contact site [same as #31 on COPA II] &length of time of contact)

WH

AT

AN

DH

OW

19. SEVERITY OF EXPOSURE (i.e. Percutaneous Exposure - depth & size of injury site; Skin Exposure – condition of skin [i.e. chapped, abraded, or intact]; Mucous-membrane – large mixing)

PART III: COPA II FORM 20. COPA II FORM COMPLETED (You must also complete): 1- YES (DATE: / / ) 2 – NO

PART IV: SIGNATURE 21. COMPLETED BY: DATE: / /20_____

Issued: 1/17/08 14 of 28

BLANK

INTENTIONALLY

15 of 28

BLANK

INTENTIONALLY

15 of 28

D E PA R T M E N T / A G E N C Y U N I T

C A S E N O .

T Y P E O F C I T Y V E H I C L E I N V O LV E D V E H I C L E N O .

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C I T Y - B O R O U G H - T O W N S H I P

O N ( S t r e e t N a m e o r H i g h w a y N o . )

I F N O T AT I N T E R S E C T I O N

S TAT I O N M A R K E R , I N T E R S E C T I N G S T R E E T

TIM

EL

OC

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ION

TY

PE

VE

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#1 (

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VE

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PE

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S T R E E T A D D R E S S

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D e p a r t m e n t o f P u b l i c P r o p e r t y

1 0 8 0 M u n i c i p a l S e r v i c e s B u i l d i n g

P h i l a d e l p h i a , P A 1 9 1 0 7

T R A F F I C A C C I D E N T R E P O R T - C I T Y V E H I C L E

C I T Y O F P H I L A D E L P H I A

AT I N T E R S E C T I O N W I T H

S A F E T Y O F F I C E R U S E O N LY

C I T Y

O W N E R ’ S N A M E

S TAT E Z I P C O D E

O P E R . B I R T H D AY O P E R AT O R ’ S J O B T I T L E AT T I M E O F A C C I D .

Y E A R M A K E

M O D E L

T Y P E O F A P P O I N T M E N T

D E P T. - V E H I C L E L I C E N S E N O . & S TAT E

E S T I M AT E D A M O U N T O F D A M A G E T OV E H I C L E

$


O P E R AT O R O R P E D E S T R I A N ’ S N A M E ( F i r s t , M i d d l e , L a s t )

C I T Y

V E H I C L E O R P R O P E R T Y O W N E R ’ S N A M E ( F i r s t , M i d d l e , L a s t )

S TAT E Z I P C O D E


C I T Y S TAT E Z I P C O D E

D E S C R I P T I O N O F D A M A G E D P R O P E R T Y

O P E R AT O R ’ S L I C E N S E N O . & S TAT E

V E H I C L E L I C E N S E N O . & S TAT E

V E H I C L E C O L O R Y E A R

O P E R AT O R ’ SB I R T H D AT E

M o . D a y Y r .

M A K E M O D E L

E S T I M AT E D A M O U N T O F D A M A G E T OV E H I C L E $

E S T I M AT E D P R O P E R T Y D A M A G E

$

N A M E A G E S E XV E H .N O .

O p e r a t o r N o . 1

I n j u r y P o s . S a f e t y

1 - N o s a f e t y d e v i c e a v a i l a b l e

2 - A v a i l a b l e b u t N O T i n u s e

3 - S e a t b e l t i n u s e

4 - L a p / S h o u l d e r H a r n e s s i n u s e

K - K i l l e d

A - M a j o r :

B - M o d e r a t e :

C - M i n o r :

D - N o I n j u r y

B l e e d i n g , D i s t o r t e d M e m b e r ,h a d t o b e r e m o v e d f r o m s c e n e

O t h e r v i s i b l e i n j u r y , b r u i s e s ,l i m p i n g , a b r a s i o n s

N o v i s i b l e i n j u r y b u t c o m p l a i n to f p a i n

1

2 3

4 5 6

1 - D r i v e r

2 - 6 - P a s s e n g e r s

7 - P e d e s t r i a n

8 - O t h e r

P

NRNP

R

C h e c k I f

H i t & R u nP a s s e n g e r C a r

P a r k e d o r S t a n d i n g V e h i c l e

O t h e r ( S p e c i f y )

A n i m a l

P e d e s t r i a n

B u i l d i n g o r F i x t u r e

O t h e r ( S p e c i f y )

C o m m e r c i a l V e h i c l e

S i d e s w i p e R e a r E n d

R i g h t A n g l e F r o n t E n d

O t h e r ( D e s c r i b e )

H e a d O n

E T C .

8 2 - S - 8 7

S U P E R V I S O RI N V E S T I G AT E D Ye s N o

P O L I C E I N V E S T I G AT E D

I f “ Y e s ” , N a m e o f D e p t .

Ye s

N o

A . M .

P. M .

:

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O P E R AT O R ’ S N A M E ( F i r s t , M i d d l e , L a s t )

16 of 28

D AT E O P E R AT O R ’ S S I G N AT U R E D AT E I N V E S T I G AT O R ’ S S I G N AT U R E

8 2 - S - 8 7 ( R e v e r s e )

GIVE A DETAILED DESCRIPTION OF THE ACCIDENT IMMEDIATELY PRIOR TO IMPACT,

AT IMPACT, AND IMMEDIATELY AFTER IMPACT, REFER TO VEHICLES BY NUMBER.

CIRCLEDAMAGED AREAOF EACH VEHICLE

INSTRUCTIONS

1. Draw Diagram As Clearly As You Can.

2. ShowYour Vehicle As Number 1.

3. Label All Streets, Highways, and Landmarks

4. Draw An Arrow In Circle Below So It Points North.

5. Complete Narrative

Indicate Northby Arrow

WEATHER ROADWAY

Clear Foggy

Rain Snow

Other Dry Icy

Wet Snowy

Other

VEHICLENO.1

LegalSpeed MPH

EstimatedSpeed MPH

VEHICLENO.2

LegalSpeed MPH

EstimatedSpeed MPH

BLANK

INTENTIONALLY

18 of 28

CITY OF PHILADELPHIA INJURY ON DUTY & WORKERS’ COMPENSATION

PROVIDER PANEL LISTING

EFFECTIVE October 2010

PROVIDER PROVIDER SERVICES

& HOURS OF OPERATION

ASSIGNED ZIP CODES

ARIA WORKHEALTH @ Aria Health Frankford Hospital WorkHealth 5000 Frankford Ave Philadelphia, Pa 19124 Phone (215) 831-2211 Emergency Services Ph: (215) 831-2086 Fax (215) 831-2271 Fx: (215) 831-5944

Occupational Clinic & Hospital Services

Hours of operation: Mon-Fri

8:30 AM-5:00 PM

19122, 19123, 19124, 19125, 19130, 19133, 19134, 19140, 19141

WORKNET @ Hahnemann Hospital Hahnemann University Hospital Broad and Vine Streets, Mail Stop 101 Philadelphia, PA 19102 Phone: 215-762-8525 Emergency Services Ph: (215) 762-7963 Fax: 215-762-1448 Fx: (215) 762-5793


Hours of operation: Mon-Fri

8:30 AM-5:00 PM

19101, 19102, 19103, 19106, 19107, 19108,

19109

BUSINESS HEALTH @ Jeanes Hospital Jeanes Hospital Jeanes Physicians’ Office Building 7600 Central Avenue, Suite 201 Philadelphia, PA 19111 Phone: 215-728-2020 Emergency Services Ph: (215) 728-2168 Fax: 215-728-2044 Fx: (215) 728-3364


Hours of operation:

Mon-Fri 8:30 AM-5:00 PM

19111, 19115, 19117, 19118, 19120, 19126, 19136, 19138, 19149,

19150, 19152

WORKHEALTH @ Aria Health Torresdale Hospital WorkHealth, Knight & Red Lion Rds, Suite 206 Medical Office Building Philadelphia, Pa 19114 Phone (215) 612-4836 Emergency Services Ph (215) 612-4056 Fax (215) 612-4904 Fx (215) 612-4284


Hours of operation:

Mon-Tue 11:30-4:00PM

Wed-Thurs 8:30 AM-4:00 PM

19114, 19116, 19154

WORKNET @ Reed Street 1 Reed Street, Philadelphia PA 19147 Phone: 215-467-5800 Emergency Services Ph: (215) 952-9130 Fax: 215-467-2022 Fx: (215) 952-5193

Occupational Clinic

Hours of operation: Mon – Fri.

7:30 AM – 5:00 PM

19112, 19113, 19142, 19145, 19146, 19147,

19148, 19153

WORKNET @ Roxborough Hospital Roxborough Memorial Hospital 5800 Ridge Avenue, Suite 234 Philadelphia, PA 19128 Phone: 215-487-4540 Emergency Services Ph: (215) 487-4334 Fax: 215-487-4544 Fx: (215) 487-4333


Hours of operation:

Mon-Fri 8:00 AM-5:00 PM

19104, 19119, 19121, 19127, 19128, 19129, 19131, 19132, 19139,

19144, 19151

Treatment Site for Bloodborne Pathogen

Injuries

Treatment Site for Bloodborne Pathogen

Injuries

19 of 28

Physical Therapy Zip Code Dissemination (City of Philadelphia) 10-5-10

Physical Therapy Provider

Address Assigned Zip Codes

La Fortaleza Physical Therapy

4231 North 5th Street, Philadelphia, PA 19140

19117, 19118, 19120, 19121, 19122, 19123, 19125, 19126, 19127, 19138, 19140, 19141, 19144, 19150

La Fortaleza Physical Therapy 3300 Aramingo Avenue, Philadelphia, PA 19134

19124, 19130, 19132, 19133, 19134, 19137

NovaCare Rehabilitation

NovaCare Rehabilitation, 6595B Roosevelt Boulevard, Philadelphia, PA 19149

19111, 19114, 19115, 19116, 19135, 19136, 19149, 19152, 19154


NovaCare Rehabilitation, 8832 Frankford Avenue, Philadelphia, PA 19136

19111, 19114, 19115, 19116, 19135, 19136, 19149, 19152, 19154


NovaCare Rehabilitation, 11596 Roosevelt Boulevard, Philadelphia, PA 19116

19111, 19114, 19115, 19116, 19135, 19136, 19149, 19152, 19154


224 South Broad Street, Philadelphia, PA 19102

19101, 19102, 19103, 19106, 19107, 19108


2401 Pennsylvania Avenue, Unit 1D5, Philadelphia, PA 19130

19101, 19102, 19103, 19106, 19107, 19108


2301-03 North Broad Street, Philadelphia, PA 19132

19119, 19128, 19129


2129 West Oregon Avenue, Philadelphia, PA 19145

19112, 19113, 19147


2410 South Broad Street, Suite 101, Philadelphia, PA 19148

19112, 19113, 19147


1 Reed Street, Philadelphia, PA 19147 19112, 19113, 19147

Mercy Health System

5008 Baltimore Avenue, Philadelphia, PA 19143

19104, 19131, 19139, 19142, 19143, 19145, 19146, 19148, 19151

Mercy Health System 5401 South 54th Street, Philadelphia, PA 19143

19142, 19143, 19145, 19146, 19148

Mercy Health System

2821 Island Avenue, Suite 172, Philadelphia, PA 19153

19153

Pro Physical Therapy

9475 East Roosevelt Boulevard, Suite B4, Philadelphia, PA 19114

All Zip Codes (Aquatics and FCE’s only)

20 of 28

CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE PROVIDER PANEL FOR

EMPLOYER ZIP CODES (19122, 19123, 19124, 19125, 19130, 19133, 19134, 19137, 19140, 19141) WORKHEALTH – FRANKFORD AVENUE

A. IMMEDIATELY REPORT THE INJURY TO YOUR SUPERVISOR. B. EMPLOYEES ELECTING CIVIL SERVICE REGULATION 32 BENEFITS MUST CONTINUE TO TREAT WITH THE DESIGNATED MEDICAL FACILITY FOR THE ZIP CODE WHERE YOU WORK.

Provider Address Phone Number Specialty 1. James U. Barnes, MD WorkHealth, 5000 Frankford Avenue Philadelphia PA 19124

HOURS OF OPERATION: MON- FRI 8:30AM-5PM P: 215-831-2211 F: 215-831-2271

OCCUPATIONAL MEDICINE (ALL CARE)

2. Drs. Horenstein, Brigham, & Colton Premier Surgical Orthopedics, 525 Jamestown Ave, Suite 105, Philadelphia. PA 19128 215-482-6693 GENERAL ORTHOPEDICS

3. Gary W. Muller, MD Jeanes, 7602 Central Ave, Suite 101 Philadelphia PA 19111 215-342-8330 GENERAL ORTHOPEDICS 4. Steven Cohen, MD Rothman Institute, 2630 Holme Avenue, Philadelphia PA 19152 267-339-3776 GENERAL ORTHOPEDICS 5. Charles Leinberry, MD Pedro Beredjiklian, MD

Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 HAND

6. Robert Frederick, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 KNEE 7. James Raphael, MD Einstein Regional Orthopedic Specialist, 9880 Bustleton Avenue

Philadelphia. PA 19115 215-827-1526 HAND

8. Amitabha Mitra, MD Hahnemann , 231 North Broad Street, 3rd Floor, Philadelphia. PA 19107 215-557-7227 PLASTIC/ HAND 9. James A. Tom, MD Hahnemann, 216 North Broad Street 2nd Floor Feinstein Building

Philadelphia. PA 19102 215-762-2663 SHOULDER / KNEE

10. Mark David Lazarus, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA

19152 267-339-3776 BACK AND SPINE

13. Steven M. Raikin, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 FOOT AND ANKLE 14. Jamal Ahmad, MD Rothman Institute, 2630 Holme Avenue, Philadelphia PA 19152 267-339-3776 FOOT AND ANKLE 15. Edward L. Chairman, DPM 1840 South Street, Philadelphia PA 19146 215-732-0200 PODIATRY 16. Lee Kirksey, MD Penn Wound Care Center, 1740 S. Street, 2nd Floor Philadelphia. PA

19146 215-893-7655 WOUND CARE

17. Harvey J. Lerner, MD 2300 East Allegheny Avenue, Philadelphia. PA 19134 215- 425-2288 GENERAL SURGERY 18. Drs. Oleginski & Meis

General & Vascular Surgical Group, 2701 Holmes Avenue, Philadelphia PA 19152 215-331-7001 GENERAL SURGERY

19. Constantinos A. Pavlides, MD Hahnemann, 245 North Broad Street, Philadelphia PA 19107 215-568-1015 GENERAL SURGERY 20. Drs. Queenan, & Kralick Hanhemann Neurosurgery, 245 North Broad Street, 7th Floor, Suite

7224 Philadelphia PA 19102 215-762-3131 NEUROSURGERY

21. Drs. Bennett & Levin Katz, Bennett and Levin Neurology Associates, Medical Arts Building, Suite 101, 50 East Township Line Road, Elkins Park, PA 19027 215-379-4300 NEUROLOGY

22. Thomas P. Costello, Jr., DO Eastern Regional Pain Management @ Jeanes Hospital, 7600 Central Avenue, Founders Building, Philadelphia. PA 19111 215-214-4303 PAIN MANAGEMENT

23. Gregory H. Pharo, DO 829 Spruce Street, Suite 308, Philadelphia, PA 19107 215-925-0986 PAIN MANAGEMENT

24. Lee D. Rowe, MD 2340 E Allegheny Ave Philadelphia. PA 19134 215-423-6670 OTORHINOLARYNGOLOGY 25. Drs. Behar & Garden Philadelphia Eye Associates, 1703 S Broad St Philadelphia. PA 19148 215-339-8100 OPHTHALMOLOGY 26. Richard E. Naids, MD 2818 Cottman Avenue Philadelphia. PA 19149 215-725-9700 OPHTHALMOLOGY 27. Dean Karalis, MD Cardiology Consultants of Philadelphia, 227 North Broad Street 2nd

Floor Philadelphia. PA 19107 215-564-3050 CARDIOLOGY

28. Kathleen J. Brennan, MD Temple Pulmonary Associates, 3401 N Broad St Philadelphia. PA 19140 215- 707-2237 PULMONARY 29. Robert N. Kessler, DC 9987 Verree Road Philadelphia. PA 19115 215-698-5800 CHIROPRACTIC

30. Luis Hincape, MSPT (19122, 19123, 19125, 19140, 19141)

La Fortaleza Physical Therapy, 4231 N. 5th Street, Philadelphia,PA,19140 215-455-5370 PHYSICAL THERAPY

31. Carmen Rivera, PT (19122, 19123, 19124, 19125, 19130, 19133, 19134, 19137)

La Fortaleza Physical Therapy, 3300 Aramingo Ave, Philadelphia,PA,19134 215-427-2242

PHYSICAL THERAPY

32. Lewis Caldwell, MSPT (All Zip Codes)

Pro Physical Therapy, 9475 East Roosevelt Boulevard, Suite B4, Philadelphia PA 19114 215-464-6200 AQUATICS & FCE’S

33. Joshua Barnet, MD Raytel Imaging - For the nearest location please call 800-453-0574 RADIOLOGY 34. ScripNet P.O. Box 379037, Las Vegas NV 89138 888-880-8562 PHARMACY 35. Logos Medical Supply 5070 Parkside Avenue, Suite 2106 Philadelphia. PA 19131 215-452-5701 DURABLE MEDICAL EQUIPMENT

36. Aria Health Frankford Division

4900 Frankford Avenue, Philadelphia, PA 19124 P: 215-831-2086 F: 215-831-5944

HOSPITAL (EMERGENCY SERVICES)

C. FOR MEDICAL TREATMENT UNDER THE WORKERS’ COMPENSATION ACT: You must select one of the physicians or physician groups listed above. You must continue to visit one of the physicians listed above or any specialist to which that provider refers you, if you need treatment, for Ninety (90) days from the date of your first visit. This requirement is in conformance with the Pennsylvania Workers’ Compensation Act, Section 306 (F) (1) (i). After Ninety (90) days, if you still need treatment, you may continue with the same physician or you may choose to go to another physician or health care provider for treatment. If you decide to go to another provider, you must notify your employer of this action within five (5) days of your visit. Your bills will be paid if your physician or health care provider reports as required (within ten days after your first visit and at least once a month as long as treatment continues). You must notify the new provider that these reports are to be submitted to: CompServices, Inc., 1717 Arch Street, 14th Floor, Philadelphia, PA 19103, 1-866-463-2524.

D. MEDICAL EMERGENCY: If you are faced with a medical emergency before or after work hours, you may secure initial emergency treatment from the emergency

facility listed above. However, any follow-up care to the emergency treatment must be with the designated health care provider listed number one (1) and two (2) above. If you are incapacitated, you may be taken to the closet emergency facility.

E. IF YOU CHOOSE TO TREAT WITH AN OUT OF STATE PROVIDER, YOU MAY BE SUBJECT TO BALANCE BILLING. CompServices, Inc., 1717 Arch Street, 14th Floor, Philadelphia, PA 19103, 1-866-463-2524

10/15/2010

21 of 28

CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE PROVIDER PANEL FOR EMPLOYER ZIP CODES

(19114, 19116, 19154) WORKHEALTH – RED LION ROAD


Provider Address Phone Number Specialty 1. Neil Mallis, MD WorkHealth, Knight & Red Lion Roads, Suite 206, Medical Office Bldg

Philadelphia PA 19114 HOURS OF OPERATION: MON, TUE, WED, FRI 8:30AM- 5:00PM, & THURS 8:30AM – 7:00PM

P: 215-612-4836 F: 215-612-4904

OCCUPATIONAL MEDICINE (ALL CARE)

2. Drs. Horenstein, Brigham, & Colton

Premier Surgical Orthopedics, 525 Jamestown Ave, Suite 105, Philadelphia. PA 19128 215-482-6693 GENERAL ORTHOPEDICS







10. Mark David Lazarus, MD

Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER

11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA

19152 267-339-3776 BACK AND SPINE


19146 215-893-7655 WOUND CARE











30. Mark Human, PT (19114, 19116, 19154)

NovaCare Rehabilitation, 6595B Roosevelt Boulevard, Philadelphia, PA 19149 215-743-2332 PHYSICAL THERAPY

31. Bernadette Wiley, MSPT (19114, 19116, 19154)

NovaCare Rehabilitation, 8832 Frankford Avenue, Philadelphia, PA 19136 215-338-0440 PHYSICAL THERAPY

32. Michelle Friedman, PT (19114, 19116, 19154)

NovaCare Rehabilitation, 11596 Roosevelt Boulevard, Philadelphia, PA 19116 215-677-8200 PHYSICAL THERAPY




37. Aria Health Torresdale Division

Knights & Red Lion Roads, Philadelphia, PA 19114 P: 215-612-4056 F: 215-612-4284 HOSPITAL (EMERGENCY SERVICES)





10/15/2010

22 of 28

CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE

PROVIDER PANEL FOR EMPLOYER ZIP CODES (19101, 19102, 19103, 19106, 19107, 19108) WORKNET @ HAHNEMANN

A. IMMEDIATELY REPORT THE INJURY TO YOUR SUPERVISOR.

B. EMPLOYEES ELECTING CIVIL SERVICE REGULATION 32 BENEFITS MUST CONTINUE TO TREAT WITH THE DESIGNATED MEDICAL FACILITY FOR THE ZIP CODE WHERE YOU WORK.

Provider Address Phone Number Specialty 1. Francis X. Burke III, MD U S Regional Occupational Health II DBA Worknet,

Broad & Vine Street, Mail Stop 101 Philadelphia. PA 19102 HOURS OF OPERATION: MON – FRI. 8:30AM – 5PM

P: 215-762-8525

F: 215-762-1448

OCCUPATIONAL MEDICINE


Premier Surgical Orthopedics, 525 Jamestown Ave, Suite 105, Philadelphia. PA 19128 215-482-6693

GENERAL ORTHOPEDICS





8. Amitabha Mitra, MD Hahnemann , 231 North Broad Street, 3rd Floor, Philadelphia. PA 19107 215-557-7227 PLASTIC/ HAND

9. James A. Tom, MD Hahnemann, 216 North Broad Street 2nd Floor Feinstein Building Philadelphia. PA 19102 215-762-2663 SHOULDER / KNEE

10. Mark David Lazarus, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA

19152 267-339-3776 BACK AND SPINE


19146 215-893-7655 WOUND CARE


General & Vascular Surgical Group, 2701 Holmes Avenue, Philadelphia PA 19152 215-331-7001

GENERAL SURGERY



21. Drs. Bennett & Levin Katz, Bennett and Levin Neurology Associates, Medical Arts Building, Suite 101, 50 East Township Line Road, Elkins Park, PA 19027

215-379-4300 NEUROLOGY



24. Lee D. Rowe, MD 2340 E Allegheny Ave Philadelphia. PA 19134 215-423-6670 OTORHINOLARYNGOLOGY 25. Drs. Behar & Garden Philadelphia Eye Associates, 1703 S Broad St Philadelphia. PA 19148 215-339-8100 OPHTHALMOLOGY 26. Richard E. Naids, MD 2818 Cottman Avenue Philadelphia. PA 19149 215-725-9700 OPHTHALMOLOGY 27. Dean Karalis, MD Cardiology Consultants of Philadelphia, 227 North Broad Street 2nd Floor

Philadelphia. PA 19107 215-564-3050 CARDIOLOGY


30. Robert Molluro, PT (19101, 19102, 19103, 19106, 19107, 19108)

NovaCare Rehabilitation, 224 S Broad St, Philadelphia, PA,19102 215-985-9390

PHYSICAL THERAPY

31. Jen Sauder, PT (19101, 19102, 19103, 19106, 19107, 19108,)

NovaCare Outpatient Rehab., 2401 Pennsylvania Ave, Unit 1D5,Philadelphia,PA,19130 215-236-3700 PHYSICAL THERAPY




36. Hahnemann University Hospital Broad & Vine Streets,Philadelphia,PA,19102 P: 215-762-7963

F: 215-246-5793 HOSPITAL (EMERGENCY SERVICES)



facility listed above. However, any follow-up care to the emergency treatment must be with the designated health care provider listed number one (1) above. If you are incapacitated, you may be taken to the closet emergency facility.


10/15/2010

23 of 28

CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE

PROVIDER PANEL FOR EMPLOYER ZIP CODES (19111, 19115, 19117, 19118, 19120, 19126, 19135, 19136, 19138, 19149, 19150, 19152) JEANES HOSPITAL


Provider Address Phone Number Specialty 1. Stephanie Y. Kao, MD BusinessHealth @ Jeanes, Jeanes Phys Office Bldg,7500 Central Ave, Suite

100,Philadelphia,PA,19111 HOURS OF OPERATION: MON – FRI. 8:30AM – 5PM

P: 215-728-2020

F: 215-728-2044





6. Robert Frederick, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 KNEE 7. James Raphael, MD Einstein Regional Orthopedic Specialist, 9880 Bustleton Avenue Philadelphia. PA

19115 215-827-1526 HAND

8. Amitabha Mitra, MD Hahnemann , 231 North Broad Street, 3rd Floor, Philadelphia. PA 19107 215-557-7227 PLASTIC/ HAND 9. James A. Tom, MD Hahnemann, 216 North Broad Street 2nd Floor Feinstein Building Philadelphia.

PA 19102 215-762-2663 SHOULDER / KNEE



11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA 19152 267-339-3776 BACK AND SPINE 13. Steven M. Raikin, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 FOOT AND ANKLE 14. Jamal Ahmad, MD Rothman Institute, 2630 Holme Avenue, Philadelphia PA 19152 267-339-3776 FOOT AND ANKLE 15. Edward L. Chairman, DPM 1840 South Street, Philadelphia PA 19146 215-732-0200 PODIATRY 16. Lee Kirksey, MD Penn Wound Care Center, 1740 S. Street, 2nd Floor Philadelphia. PA 19146 215-893-7655 WOUND CARE 17. Harvey J. Lerner, MD 2300 East Allegheny Avenue, Philadelphia. PA 19134 215- 425-2288 GENERAL SURGERY 18. Drs. Oleginski & Meis


19. Constantinos A. Pavlides, MD Hahnemann, 245 North Broad Street, Philadelphia PA 19107 215-568-1015 GENERAL SURGERY 20. Drs. Queenan, & Kralick Hanhemann Neurosurgery, 245 North Broad Street, 7th Floor, Suite 7224

Philadelphia PA 19102 215-762-3131 NEUROSURGERY




24. Lee D. Rowe, MD 2340 E Allegheny Ave Philadelphia. PA 19134 215-423-6670 OTORHINOLARYNGOLOGY 25. Drs. Behar & Garden Philadelphia Eye Associates, 1703 S Broad St Philadelphia. PA 19148 215-339-8100 OPHTHALMOLOGY 26. Richard E. Naids, MD 2818 Cottman Avenue Philadelphia. PA 19149 215-725-9700 OPHTHALMOLOGY 27. Dean Karalis, MD Cardiology Consultants of Phila.., 227 N. Broad St., 2nd FL, Philadelphia.

PA 19107 215-564-3050 CARDIOLOGY


.5

30. Luis Hincape, MSPT (19117, 19118, 19120, 19126, 19138, 19150)

La Fortaleza Physical Therapy, 4231 N. 5th Street, Philadelphia,PA,19140 215-455-5370

PHYSICAL THERAPY

31. Mark Human, PT (19111,19115,19135,19136,19149, 19152)

NovaCare Rehabilitation, 6595B Roosevelt Boulevard, Philadelphia, PA 19149 215-743-2332

PHYSICAL THERAPY

32. Bernadette Wiley, MSPT (19111,19115,19135,19136,19149, 19152)

NovaCare Rehabilitation, 8832 Frankford Avenue, Philadelphia, PA 19136 215-338-0440 PHYSICAL THERAPY

33. Michelle Friedman, PT (19111,19115,19135,19136,19149, 19152)

NovaCare Rehabilitation, 11596 Roosevelt Boulevard, Philadelphia, PA 19116 215-677-8200 PHYSICAL THERAPY



35. Joshua Barnet, MD Raytel Imaging - For the nearest location please call 800-453-0574 RADIOLOGY 36. ScripNet P.O. Box 379037, Las Vegas NV 89138 888-880-8562 PHARMACY 37. Logos Medical Supply 5070 Parkside Avenue, Suite 2106, Philadelphia. PA 19131 215-452-5701 DURABLE MEDICAL

EQUIPMENT

38. Jeanes Hospital 7600 Central Ave,Philadelphia,PA,19111 P: 215-728-2169 F: 215-728-3364






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CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE PROVIDER PANEL FOR EMPLOYER ZIP

CODES (19104, 19119, 19121, 19127, 19128, 19129, 19131, 19132, 19139, 19144, 19151) WORKNET @ ROXBOROUGH


Provider Address Phone Number Specialty 1. Ruben H. Zabaleta, MD Philadelphia Occupational Health, PC dba Worknet, Roxborough Memorial

Hospital, 5800 Ridge Ave Ste 234,Philadelphia,PA,19128 HOURS OF OPERATION: MON – FRI. 8AM – 5PM

P: 215-487-4540

F: 215-487-4544



Premier Surgical Orthopedics, 525 Jamestown Ave, Suite 105, Philadelphia. PA 19128 215-482-6693 GENERAL ORTHOPEDICS







10. Mark David Lazarus, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER

11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA 19152 267-339-3776 BACK AND SPINE 13. Steven M. Raikin, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 FOOT AND ANKLE 14. Jamal Ahmad, MD Rothman Institute, 2630 Holme Avenue, Philadelphia PA 19152 267-339-3776 FOOT AND ANKLE 15. Edward L. Chairman, DPM 1840 South Street, Philadelphia PA 19146 215-732-0200 PODIATRY 16. Lee Kirksey, MD Penn Wound Care Center, 1740 S. Street, 2nd Floor Philadelphia. PA 19146 215-893-7655 WOUND CARE 17. Harvey J. Lerner, MD 2300 East Allegheny Avenue, Philadelphia. PA 19134 215- 425-2288 GENERAL SURGERY 18. Drs. Oleginski & Meis


19. Constantinos A. Pavlides, MD Hahnemann, 245 North Broad Street, Philadelphia PA 19107 215-568-1015 GENERAL SURGERY 20. Drs. Queenan, & Kralick Hanhemann Neurosurgery, 245 North Broad Street, 7th Floor, Suite 7224

Philadelphia PA 19102 215-762-3131 NEUROSURGERY



23. Lee D. Rowe, MD 2340 E Allegheny Ave Philadelphia. PA 19134 215-423-6670 OTORHINOLARYNGOLOGY 24. Drs. Behar & Garden Philadelphia Eye Associates, 1703 S Broad St Philadelphia. PA 19148 215-339-8100 OPHTHALMOLOGY 25. Richard E. Naids, MD 2818 Cottman Avenue Philadelphia. PA 19149 215-725-9700 OPHTHALMOLOGY 26. Dean Karalis, MD Cardiology Consultants of Phila., 227 N. Broad St., 2nd FL, Philadelphia. PA

19107 215-564-3050 CARDIOLOGY


29. Luis Hincape, MSPT (19121, 19127, 19144)

La Fortaleza Physical Therapy, 4231 N. 5th Street, Philadelphia,PA,19140 215-455-5370 PHYSICAL THERAPY

30. Carmen Rivera, PT (19132)

La Fortaleza Physical Therapy, 3300 Aramingo Ave, Philadelphia,PA,19134 215-427-2242 PHYSICAL THERAPY

31. Thomas Davis, PT ( 19119, 19128, 19129)

NovaCare Rehabilitation, 2301-03 N Broad Street, Philadelphia, PA,19132 215-228-2656 PHYSICAL THERAPY

32. Matt Gillane, PT (19104, 19131, 19139, 19151)

Mercy Health System, 5008 Baltimore Avenue, Philadephia, PA 19143 215-764-8500 PHYSICAL THERAPY




37. Roxborough Memorial Hospital 5800 Ridge Ave,Philadelphia,PA,19128 P: 215-487-4334 F: 215-487-4333


C. FOR MEDICAL TREATMENT UNDER THE WORKERS’ COMPENSATION ACT: You must select one of the physicians or physician groups listed above. You must continue to visit one of the physicians listed above or any specialist to which that provider refers you, if you need treatment, for Ninety (90) days from the date of your first visit. This requirement is in conformance with the Pennsylvania Workers’ Compensation Act, Section 306 (F) (1) (i). After Ninety (90) days, if you still need treatment, you may continue with the same physician or you may choose to go to another physician or health care provider for treatment. If you decide to go to another provider, you must notify your employer of this action within five (5) days of your visit. Your bills will be paid if your physician or healthcare provider reports as required (within ten days after your first visit and at least once a month as long as treatment continues). You must notify the new provider that these reports are to be submitted to: CompServices, Inc., 1717 Arch Street, 14th Floor, Philadelphia, PA 19103, 1-866-463-2524.




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CITY OF PHILADELPHIA REGULATION 32 PENNSYLVANIA WORKERS’ COMPENSATION ACT DESIGNATED HEALTH CARE PROVIDER PANEL FOR EMPLOYER ZIP CODES (19112,19113, 19142, 19143,

19145, 19146, 19147, 19148, 19153) WORKNET - REED STREET


Provider Address Phone Number Specialty 1. Lawrence Axelrod, MD

Worknet, 1 Reed Street, Philadelphia, PA 19147 HOURS OF OPERATION: MON – FRI. 7:30AM – 5 PM P: 215-467-5800

F: 215-467-2022



3. Gary W. Muller, MD Jeanes, 7602 Central Ave, Suite 101 Philadelphia PA 19111 215-342-8330 GENERAL ORTHOPEDICS 4. Steven Cohen, MD Rothman Institute, 2630 Holme Avenue, Philadelphia PA 19152 267-339-3776 GENERAL ORTHOPEDICS 5. .Charles Leinberry, MD Pedro Beredjiklian, MD








11. Matthew Ramsey, MD Rothman Institute, 925 Chestnut St., 5th FL, Philadelphia. PA 19107 267-339-3776 SHOULDER 12. David Greg Anderson, MD Rothman Institute, 2630 Holme Avenue, Suite 200, Philadelphia PA

19152 267-339-3776 BACK AND SPINE


19146 215-893-7655 WOUND CARE

17. Harvey J. Lerner, MD 2300 East Allegheny Avenue, Philadelphia. PA 19134 215-425-2288 GENERAL SURGERY 18. Drs. Oleginski & Meis




21. Drs. Bennett & Levin Katz, Bennett and Levin Neurology Associates, Medical Arts Building, Suite 101, 50 East Township Line Road, Elkins Park, PA 19027

215-379-4300 NEUROLOGY





29. Dean Penuel, PT (19112, 19113, 19147) NovaCare Rehabilitation, 2129 W Oregon Ave, Philadelphia,PA,19145 215-336-6630 PHYSICAL THERAPY

30. Daniel Walls PT (19112, 19113, 19147)

NovaCare Rehabilitation, 2410 S Broad Street, Suite 101, Philadelphia,PA,19148 215-334-4400 PHYSICAL THERAPY

31. Michael Marchesani, PT (19112, 19113, 19147)

NovaCare Rehabilitation, 1 Reed Street, Philadelphia, PA 19147 215-467-5800 PHYSICAL THERAPY

32. Matt Gillane, PT (19142, 19143, 19145, 19146, 19148)

Mercy Health System, 5008 Baltimore Avenue, Philadephia, PA 19143 215-764-8500 PHYSICAL THERAPY

33. Kelly Duszak, PT (19142, 19143, 19145, 19146, 19148)

Mercy Health System, 5401 South 54th Street, Philadelphia, PA 19143 215-748-9160 PHYSICAL THERAPY

34. Heather Morrison, PT (19153) Mercy Health System, 2821 Island Avenue, Suite 172, Philadelphia, PA 19153 215-863-2327 PHYSICAL THERAPY



36. Joshua Barnet, MD Raytel Imaging - For the nearest location please call 800-453-0574 RADIOLOGY 37. ScripNet P.O. Box 379037, Las Vegas NV 89138 888-880-8562 PHARMACY 38. Logos Medical Supply 5070 Parkside Avenue, Suite 2106 Philadelphia. PA 19131 215-452-5701 DURABLE MEDICAL

EQUIPMENT

39. Methodist Hospital 2301 South Broad Street, Philadelphia, PA 19148 P: 215-952-9130 F: 215-952-5193




facility listed above. However, any follow-up care to the emergency treatment must be with the designated health care provider listed number one (1) and two (2) above. If you are incapacitated, you may be taken to the closet emergency facility

E. IF YOU CHOOSE TO TREAT WITH AN OUT OF STATE PROVIDER, YOU MAY BE SUBJECT TO BALANCE BILLING CompServices, Inc., 1717 Arch Street, 14th Floor, Philadelphia, PA 19103, 1-866-463-2524

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BLANK

INTENTIONALLY

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Medical Health Care Provider Referral Authorization and Employee Notification

City of Philadelphia Office of the Director of Finance

Risk Management Division PAYROLL NUMBER DATE OF INJURY BADGE NUMBER (POLICE) EMPLOYEE NAME – LAST FIRST M.I.

DEPARTMENT UNIT SITE REFERRED TO TIME OF INJURY TIME LEFT JOB TIME RETURNED TO JOB

DESCRIBE ACCIDENT/INJURY IN DETAIL

ISSUANCE OF REFERRAL FORM IS NOT DETERMINATION OF SERVICE CONNECTED DISABILITY PREVIOUS EMERGENCY TREATMENT BY HOSPITAL OR DOCTOR IF ANY

NAME ADDRESS

Failure to report for medical appointments and/or seeking treatment and care by a physician not approved by City of Philadelphia may result in loss of Civil Service Regulation 32 benefits, Heart and Lung Benefits and/or other benefits. Referral for treatment after initial referral or greater than 48 hours must be from Safety Office

Your Rights and Responsibilities Concerning Medical Treatment

Under the New Worker’s Compensation Act 57 (Effective August 23, 1996)

This notice shall serve to advise you of your rights and responsibilities under the Pennsylvania Workers’ Compensation Act. (Please note that this does not change the requirement that employees MUST continue to treat exclusively with network physicians as one of the conditions of receiving Regulation 32 benefits and/or Heart and Lung Benefits). Employees electing to be covered by Workers’ Compensation benefits instead of Heart and Lung or Regulation 32 benefits should follow the medical treatment notification rights and responsibilities outlined below. If you sustain a work-related injury requiring medical treatment, you are required to first treat with a doctor who is on a City posted panel of network medical health care providers. These listings are posted at your work location. If you cannot locate a panel at our work site, your supervisor or Safety Officer can provide you one upon request. You must treat with one of the providers on the list for ninety (90) days from the first visit. If invasive surgery is recommended by the designated panel medical provider, then you are permitted a second opinion by a physician of your choice and the City is required to pay for this. If the second opinion differs from the first opinion, you have the right to determine which course of treatment you which to follow, provided that the second opinion provides a specific and detailed course of treatment. If you choose to follow the procedures recommended by the second opinion medical provider, such procedures shall be performed by one of the physicians or health care providers so designated by the City for a period of ninety (90) days from the date of the second opinion visit. Second opinion providers may not provide treatment until 90 days have elapsed from the visit to the physician or other healthcare provider of your choice. Treatment with your panel network medical care provider in violation of the above may result in denial of payment for those services rendered which were in violation. After ninety (90) days of treatment by a valid panel health care provider, an employee may choose to treat with any physician or health care provider of their choice. You must notify your employer of your choice of provider within 5 days of the first visit. Failure to notify the employer may result in non-payment of those medical bills until proper notice is given. The name of the City Third Party Administrator is CompServices, Inc., P.O. Box 58579, Philadelphia, PA 19102. Their phone number is (866) 463-2524 Employee was provided with a copy of this notice and was explained its contents.

EMPLOYEE (SIGNATURE) TELEPHONE NUMBER (WORK)

DATE

SUPERVISOR OR SAFETY OFFICER (SIGNATURE) TELEPHONE NUMBER (WORK)

DATE

82-S-98 (Rev. 8/10) 28 of 28

Documents

PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH