Job Related Injury or Illness Internal Process

Responsible Party Required Action
Injured Employee
  1. Immediately report job-related injury or illness to supervisor and seek appropriate medical care..
  2. Request and complete Employee's Claim for Workers' Compensation Benefits (DWC Form 1).
  1. Arrange for appropriate medical care.
  2. Complete required forms:
    1. Employee's Claim for Workers' Compensation Benefits (DWC Form 1).
    2. Supervisor's Injury Prevention Report (STD. 620).
    3. Fax both forms to Human Resources within 24 hours of knowledge of injury
  3. Notify employee about Return-to-Work Program, maintain contact and encourage early return to work.
  4. Notify Human Resources and departmental attendance clerk when employee misses work or returns to work.
Human Resources
  1. Complete Employer's Report for Occupational Injury or Illness (Form 5020) and send to the Third Party Administrator (TPA), along with copy of DWC Form 1 and STD 620.
  2. Send copies of STD. 620 and DWC Form 1 to Environmental Health and Safety officer.
  3. Return copy of DWC Form 1 to employee.
  4. Send copy of Supervisor's Injury Prevention Report (STD 620) to supervisor.
  5. Establish and maintain regular contact with TPA claims adjustor regarding status of claims.
  6. Provide TPA with all documentation they may require to process claims. These include but are not limited to: first injury reports, doctor's statements, return to work statements, job descriptions, etc.
Environmental Health and Safety Officer
  1. Investigate injury/illness if warranted, and report finding to department management and Human Resources.
Third Party Administrator (TPA)
  1. Conduct further investigation to determine if work related.
  2. Approve/deny claim.
  3. Establish and maintain regular contact with Human Resources staff to process claims, IDL notifications and other responsibilities necessary to providing a comprehensive workers' compensation program.