City of Waltham

CITY OF WALTHAM

WORKERS’ COMPENSATION INFORMATIONAL BOOKLET AND FORMS

“The Best Way To Treat An Injury Is To Prevent It”

CITY OF WALTHAM

WC Info Booklet and Forms 9-28-2011 Workers’ Compensation Informational Booklet and Forms

Table of Contents

Page(s)

Introduction 3

Injury Reporting Requirements 5

Employer’s First Report of Injury 6-7

Employee’s Notice of Injury 8

Retirement Board Form 9

Supervisor’s Accident Investigation Report 10

Witness Report(s), if applicable 11

Medical Records Release 12

Guidelines for Using Mount Auburn Occupation Health 13

Guidelines for Deciding the Most Appropriate 14 Option for Care

WC Info Booklet and Forms 2 CITY OF WALTHAM

WORKERS’ COMPENSATION INFORMATIONAL BOOKLET AND FORMS

INTRODUCTION

The purpose of this manual is to establish consistent procedures for all employees of the City of Waltham to enable the City to respond promptly and effectively to any work related injury and/or illness of its employees while complying with the obligations of Chapter 152 of the Massachusetts General Laws, “The Workers’ Compensation Act.”

MANAGING INJURIES

In order to provide a prompt and effective response to any work related injury or illness, it is imperative that personnel be instructed to manage the injury and not to react to it. Managing the injury means being proactive and involves taking action both before and after the occurrence of an injury or illness. The difference is in the concept of accident investigation and prevention versus just reporting the accident and watching our injury costs grow and grow.

1. Medical care

Once an injury or illness has occurred, the City’s primary objective is to promptly provide the injured or ill employee with quality first aid and/or medical care. Employees must report all work related injuries and illnesses to their supervisor, no matter how minor or insignificant they may appear. When medical care is required, employees will be referred to Mount Auburn Hospital Occupation Health, 725 Concord Avenue, Suite 5100, Cambridge, MA 02138, Monday – Friday 8:00 a.m. – 4:30 p.m. No appointment is necessary, but if possible please call first 617- 354-0546. If it is an emergency between the hours of 4:30 pm and 8:00 am please report to Mount Auburn Hospital Emergency Room, 330 Mount Auburn Street, Cambridge, MA, if possible please call first 617-499-5025 or report to the closest emergency room.

SCHOOL DEPARTMENT – All work related injuries should be evaluated by the School Nurse and reported to the building Principal or Department Head. In the event that there is no nurse on duty, employees requiring medical care will be referred to Mount Auburn Hospital Occupation Health, 725 Concord Avenue, Suite 5100, Cambridge, MA 02138, Monday – Friday 8:00 a.m. – 4:30 p.m. No appointment is necessary, but if possible please call first 617-354-0546. If it is an emergency between the hours of 4:30 pm and 8:00 am please report to Mount Auburn Hospital Emergency Room, 330 Mount Auburn Street, Cambridge, MA, if possible please call first 617-499-5025 or report to the closest emergency room.

WC Info Booklet and Forms 3 2. Communication

Within your department establish a written set of step-by-step instructions for the communication of all work related injuries or illnesses. These instructions should be applicable to both minor and major injuries or illnesses and should provide for the notification of the Personnel Department. A copy of the instructions must be provided to the Personnel Department.

3. Accident Investigation

Designate a person to be responsible for investigating the injury or illness as well as collecting and completing all necessary forms and reports.

4. Prevention

Aim to reduce accident frequency by developing and enforcing safe work procedures within your department. As the old saying goes, “An ounce of prevention is worth a pound of cure.”

ELIGIBILITY

An injured or ill employee becomes eligible for Workers’ Compensation benefits when he/she sustains a work related injury or illness and is incapacitated from earning wages for five or more calendar days (the days do not have to be consecutive).

If the employee is incapacitated for twenty days or less, workers’ compensation benefits shall only be paid from the sixth day. Days one through five shall be paid from the employee’s accrued sick leave benefits unless the employee has insufficient sick leave benefits or specifically informs the City that his/her sick leave benefits shall not be used.

If, however, the incapacitation extends for a period of twenty-one days or more, compensation shall be paid from the first day.

WC Info Booklet and Forms 4 INJURY REPORTING REQUIREMENTS

The following original completed forms must be submitted to the Personnel Department within 24 hours of the injury or illness (all forms must be legible and in ink):

Form Responsible for Completing

Employer’s First Report of Injury Personnel

Employee’s Notice of Injury Employee

City of Waltham Retirement System Notice of Injury Employee

Supervisor’s Accident Investigation Report Supervisor

Witness Report(s), if applicable All witnesses to the injury

Medical Records Release Employee

It is the responsibility of every Department Head and School Principal to ensure that all required information is provided to the Personnel Department within the specified time. Delays in providing this information are unacceptable and contribute to our inability to provide prompt and effective services to injured employees, and could result in substantial fines being levied against the City by the Industrial Accident Board. We anticipate your full cooperation.

If there are any questions or comments, or if you require additional forms or information, the Personnel Department can be reached at 781-314-3355 or e-mail address is [email protected]

Mailed correspondence should be addressed as follows:

Personnel Department City of Waltham 119 School Street Waltham, MA 02451 781-314-3358 (FAX)

WC Info Booklet and Forms 5 FORM 101 The Commonwealth of Massachusetts DIA USE ONLY Department of Industrial Accidents – Department 101 600 Washington Street – 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia

EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY

THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES. INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print legibly or type - Unreadable forms will be returned.

E 1. Employee’s Name (Last, First, MI): 2. Home Telephone Number: 3. Social Security 4. Sex: M F M Number*: P L 5. Home Address (No., Street, City, State & Zip Code): 6. Marital Status: M S 7. No. of Dependents: O Y 8. Date of Hire (mm/dd/yyyy): 9. Date of Birth (mm/dd/yyyy): 10. Average Weekly Wage: Estimated Actual$ E E 11. Employer’s Name: 12. Federal Tax I.D. Number: E M 13. Employer’s Address (No., Street, City, State & Zip Code): 14. Employer’s Telephone Number: P L 15. Industry Code (See Reverse Side): O 16. Workers’ Compensation Insurance Carrier and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR): 17. W.C. Policy Number: Y E R 19. Business Type : Service Wholesale Mfg. Retail 18. Self-Insured? Yes No If Yes, Self-Insurer Number: Other ______

20. DATE OF INJURY (mm/dd/yyyy):

I 21. Was Employee Injured on Employer’s Premises? Yes No 22. Location of Injury if not on Employer’s Premises: N J 23. FIRST day of Total or Partial Incapacity to Earn Wages 24. FIFTH day of Total or Partial Incapacity to Earn Wages U (mm/dd/yyyy): (mm/dd/yyyy): R Y 25. If Employee has Died, Date of Death (mm/dd/yyyy): 26. Source of Injury (Chemicals, Machinery, etc.):

I N 27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: F O R 28. Person to Whom Injury was Reported (list position): 29. Date Reported (mm/dd/yyyy): 30. Date Reported as work related M (mm/dd/yyyy): A 31. Injury Code(s) a. to body part b. to body part c. to body part Body Part 32. Witness(es) to Injury - Give Full Name(s), if none state as such: T Code(s) a. b. c. I O 33. Has Employee Returned to Work? Yes No 34. Date Employee Returned to Work(mm/dd/yyyy): N

35. Employee’s Regular Occupation: 36. Has Employee Returned to Regular Occupation: Yes No

37. EMPLOYER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE): 38. Title:

39. EMPLOYER’S Signature (SEE INSTRUCTIONS ON REVERSE 40. Date Prepared (mm/dd/yyyy): SIDE):

*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report. Form 101 -Revised 8/2001 - Reproduce as needed. THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.

WC Info Booklet and Forms 6 EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY

FILING INSTRUCTIONS 1 WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages. This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is not entitled to benefits under M.G.L. Chapter 152. 2 WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be provided to the Employee and to the Employer’s Workers’ Compensation insurer. 3 PENALTIES: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6. 4 EMPLOYER’S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the employer.

INDUSTRY CODES Agriculture, Forestry and Fishing 01 28 Chemicals and Allied Products 29 Petroleum and Coal Products 30 Rubber and Misc. Plastic 78 Motion Pictures 79 Amusements and Recreation Agriculture Production - Crops 02 Products 31 Leather and Leather Products 32 Stone, Clay and Glass Products 33 Primary Metal Services 80 Health Services 81 Legal Services 82 Agriculture Production - Livestock 07 Industries 34 Fabricated Metal Products 35 Industrial Machinery and Equipment 36 Electronic and Educational Services 83 Social Services 84 Agricultural Services 08 Forestry 09 Fishing, Other Electrical Equipment 37 Transportation Equipment 38 Instruments and Related Products 39 Museums, Botanical, Zoological Gardens 86 Hunting and Trapping Mining 10 Metal Miscellaneous Manufacturing Industries Transportation and Public Utilities 40 Railroad Membership Organizations 87 Engineering and Mining 12 Coal Mining 13 Oil and Natural Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Management Services 88 Private Households 89 Gas 14 Nonmetallic Minerals, Except Fuels Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Services, NEC Public Administration 91 Executive, Construction 15 General Building Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade Legislative and Garden 92 Justice, Public Order, Contractors 16 Heavy Construction, Ex. 50 Wholesale Trade - Durable Goods 51 Wholesale Trade - Non-durable Goods Retail Trade 52 and Safety 93 Finance, Taxation, and Monetary Building 17 Special Trade Contractors Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Benefits 94 Administration of Human Services 95 Manufacturing 20 Food and Kindred Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Environmental Quality and Housing 96 Products 21 Tobacco Products 22 Textile Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Administration of Economic Program 97 National Mill Products 23 Apparel and Other Textile Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers Security and International Affairs Non-classifiable Products 24 Lumber and Wood Products 25 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Establishments 99 Non-classifiable Establishments Furniture and Fixtures 26 Paper and Allied Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Products 27 Printing and Publishing Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services

NATURE OF INJURY OR ILLNESS CODES 100 Amputation or Erucloation 110 Asphyxia 157 Tuberculosis 159 Other Infective or Parasitic Diseases Dermatitis 180 Dermatitis, UNS* 183 Other 265 Carpal Tunnel Syndrome 510 or Strangulation Etc. 120 Burns (Heat) 130 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Cardiovascular and Other Conditions of the Burns (Chemical) 140 Concussion 160 Skin Condition, NEC** Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Circulatory System 520 Complications Peculiar to Contusion, Crushing, Bruise 170 Cut, Materials other than Lead 272 Diseases of the Blood and Blood Forming Organs 273 Upper Medical Care 500 Effects of Changes in Laceration, Puncture 190 Dislocation 200 Respiratory Conditions 274 Influenza, Pneumonia, Etc. 276 Other Diseases of the Gastro-Intestinal Atmospheric Pressure 240 Effects of Environmental Electric Shock, Electrocution 210 Fracture Tract 278 Effects of Lead 279 Other Toxic Effects of One System Only Respiratory Systems, Heat 220 Effects of Exposure to Low Temperature 250 Hernia, Rupture 300 Scratches, Conditions of 570 Respiratory Systems, Conditions of 571 Upper Respiratory 572 Asthma, Influenza, 530 Eye, other Diseases of the Eye 230 Hearing Abrasions 310 Sprains, Strains 400 Multiple Pneumonia Pneumoconiosis 280 Pneumoconiosis 281 Aluminosis 282 Anthracosis 283 Asbestosis Loss or Impairment 991 Heart Condition ,Excludes Injuries 900 No Injury 950 Damage to 284 Byssinosis 285 Siderosis 286 Silicosis 287 Other Pneumoconioses 289 Pneumoconiosis and Heart Attack 320 Hemorrhoids 330 Hepatitis, Prosthetic Devices 995 No Other Injury, Tuberculosis Nervous System, Conditions of 560 Nervous System, Conditions of - NEC** 561 Serum and Infective 275 Hepatitis, Toxic 260 NEC** 999 Non-classifiable Infective or Diseases of the Central Nervous System 562 Diseases of the Nerves and Peripheral Ganglia Inflammation of Joints, Etc. 540 Mental Disorders Parasitic Disease 150 Infective or Parasitic Neoplasm Tumor 550 Neoplasm Tumor, UNS* 551 Malignant 552 Benign Radiation Effects 290 900 No Illness 999 Non-classifiable 990 Disease, UNS* 151 Amebiasis 152 Anthrax Radiation Effects, UNS* 291 Non-Ionizing Radiation 292 Microwaves 293 Ionizing Radiation - X- Occupational Disease, NEC** 580 Symptoms and 153 Brucellosis 154 Conjunctivitis and Ray 294 Ionizing Radiation - Isotopes 295 Welder’s Flash Ill-defined Conditions Opthalmia 156 Tetanus

BODY PART AFFECTED CODES Head 100 Head, UNS* 110 Brain 120 Ear(s), 160 Skull 198 Head Multiple 200 Neck & Cervical Vertebrae UPPER EXTREMITIES 300 Upper 513 Knee(s) 515 Lower Leg(s) 518 Leg(s), Multiple UNS* 121 Ear(s), External 124 Ear(s), Extremities, NEC** 310 Arm(s), UNS* 311 Upper Arm 313 Elbow(s) 315 Forearm(s) 318 Arm(s), 519 Leg(s), NEC** 520 Ankle(s) 530 Foot or Feet, Internal 130 Eye(s), UNS* 140 Face, UNS* Multiple 319 Arm(s), NEC** 320 Wrist(s) 330 Hand(s), Not Wrists or Fingers 340 Finger(s) 398 Not Ankle 540 Toe(s) 598 Lower Extremities, 141 Jaw, Chin 144 Mouth and Throat (vocal Upper Extremities, Multiple 400 Trunk, UNS* 410 Abdomen, Internal Organs, Inguinal Hernia 420 Multiple 700 MULTIPLE PARTS Applies when chords, larynx) 146 Nose 148 Face, Multiple Back 430 Chest, Ribs, Breastbone, Internal Organs 440 Hip(s)..,Pelvis, Organs and Buttocks 450 more than one major body part as been effected Parts 149 Face, NEC** 150 Scalp Shoulder(s) 498 Trunk, Multiple LOWER EXTREMITIES 500 Lower Extremities 510 Leg(s), UNS* such as an arm and a leg 999 NON- CLASSIFIABLE - Insufficient infor mation to identify part of body effected. Includes damage to prosthetic devises.

*UNS - UNSPECIFIED **NEC - NOT ELSEWHERE LASSIFIED

WC Info Booklet and Forms 7 CITY OF WALTHAM EMPLOYEE’S NOTICE OF INJURY (PLEASE ANSWER ALL QUESTIONS ACCURATELY AND COMPLETELY)

NOTE: Each time an employee is injured or suffers a recurrence of a previous job related injury; this form must be completed by the employee and submitted to his/her Supervisor or Department Head and the Personnel Department immediately.

Name of Injured Employee __Telephone Number______

Home Address Zip Code ______Date of Birth Marital Status No. of Dependents ______Department Position Date of Hire ______Date of Accident ______Time of Accident ______Location of Accident ______Name(s) of any Witness (es) ______Description of Accident: What were you doing at the time of the accident? ______Describe how the accident occurred ______Describe any injuries you sustained ______Detail all medical services received ______Could the accident have been avoided? (Yes/No/Explain) ______Equipment, Tools & Materials Involved ______Weather conditions leading to or causing the incident ______Have you returned to work? Date you returned to work ______Please list any days absent due to the injury ______Signature Date ______(Injured Employee)

WC Info Booklet and Forms 8 NOTE: This form should be filed with the Retirement Board “By the member or in his behalf WITHIN 90 DAYS” from the date of accident or hazard undergone after July 1, 1937. CITY OF WALTHAM RETIREMENT SYSTEM NOTICE OF INJURY

This is to notify you that received injuries incurred through (Full name of employee) accident in the line of duty or due to a hazard which occurred in like line of duty while employed in the service at the on and whose home address is (Name of Dept. or Institution) (Month) (Day) (Year)

(Street and Number) (City or Town) (Write the word) If married SINGLE 1. 1a. Husband of MARRIED (Give maiden name of wife in full)

2. Date of Birth 2a. Date of entry in service (Month) (Day) (Year) 3. The cause of injury was (Describe cause of injury)

(If statement requires more space use other side of this blank and write in this space –SEE OTHER SIDE)

(Important: Sign your name after what you write on other side)

4. The nature of injury is as follows Describe injury with such exactness as possible

IMPORTANT—Nos. 5, 6, and 7 must not be left blank. Some statement must be made. EXAMPLE: Not taken to a hospital; No witness, etc.

5. NAME AND ADDRESS OF DOCTOR WHO ATTENDED EMPLOYEE (Full Name) Address (Street and number) (City) (State) 6. NAME AND ADDRESS OF HOSPITAL (Full Name) Address (Street and number) (City) (State) 7. NAME AND ADDRESS OF WITNESS (If possible give two names of eyewitnesses.) 1. Name Address No. Street City or town State (Zip) 2. Name Address No. Street City or town State (Zip) IMPORTANT—Nos. 5, 6, and 7 must not be left blank. Some statement must be made. EXAMPLE: Not taken to a hospital; No witness, etc. Signature (Of employee or other informant)

(If other informant, relationship or title of superior officer) IMPORTANT The Law requires that injuries incurred in line of duty AFTER JULY 1, 1938, shall be reported to the RETIREMENT BOARD WITHIN NINETY DAYS to give unlimited time coverage for (1) retirement based upon accidental injuries or (2) an accidental death benefit.

WC Info Booklet and Forms 9 IF the NOTICE OF INJURY is not so filed WITHIN NINETY DAYS an APPLICATION for (1) accidental disability retirement, or (2) for a death benefit based upon accidental injuries incurred MORE THAN TWO YEARS PRIOR to the date of application, IS VOID. CITY OF WALTHAM SUPERVISOR’S ACCIDENT INVESTIGATION REPORT (PLEASE ANSWER ALL QUESTIONS ACCURATELY AND COMPLETELY)

Name of Injured Employee Date of This Report ______Department Position Date of Hire ______Date of Accident Time of Accident ______Location of Accident ______Name(s) of any Witness ______When the injury was first reported? ______If more than 24 hours after accident occurred, explain reason for the delay. ______Nature of the injury (i.e., left/right ankle, wrist, shoulder, etc.) ______Describe how the accident happened. (Detail employee’s actions as well as all relevant circumstances)

______

Was the employee using proper safety equipment and observing all relevant safety precautions/procedures? (Yes/No/Explain)

______Department Head Comments

WC Info Booklet and Forms 10

______Signature Signature ______Supervisor Department Head

WC Info Booklet and Forms 11 CITY OF WALTHAM WITNESS REPORT (PLEASE ANSWER ALL QUESTIONS ACCURATELY AND COMPLETELY)

NOTE: A separate form is to be completed by ALL witnesses to any job related accident involving a City of Waltham employee.

Witness’ Name Date ______Department Position ______Home Address City Zip Code ______Name of Injured Employee Date of Injury ______Time of Injury Description of the Accident: Describe what you saw and heard at the time of the accident. ______What did the employee say at the time he/she was injured? ______Did the employee continue to work after the accident? ______Could the accident have been avoided? (Yes/No/Explain) ______Signature _____ Date Witness

WC Info Booklet and Forms 12 Authorization to Use and Disclose Protected Health Information for Purposes Other Than Payment, Treatment and Healthcare Operations

Patient Name:

Home Address:

Tel. No. Date of Birth:

RECORDS/INFORMATION TO BE DISCLOSED:

All medical records or information of any kind created and/or maintained by your office with respect to the above-named patient.

RECIPIENT: You may disclose this information by mailing the records to:

Kristin Murphy City of Waltham Personnel Director 119 School Street, Waltham, MA 02451.

TERM: This Authorization will remain in effect for one (1) year from the date of execution.

By my signature below, I hereby authorize you to use and/or disclose to the recipient my health information for the term of this Authorization notwithstanding and/or subject to the following:

I understand that once you disclose my health information to the recipient, you cannot guarantee that the recipient will not re-disclose my health information to a third party. Any such third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of your treatment of me; except, however, if my treatment by you is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case you may refuse to treat me if I do not sign this Authorization.

I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to you at your usual business address. The revocation will be effective immediately upon your receipt of my written notice, except that the revocation will not have any effect on any action taken by you in reliance on this Authorization before you received my written notice of revocation.

I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the use and disclosure of my health information. By my signature below, I hereby, knowingly and voluntarily, authorize you to use and/or disclose my health information in the manner described above.

A copy of this document will suffice as proper authorization.

______Signature of Patient Date

WC Info Booklet and Forms 13 Guidelines for Mount Auburn Occupation Health

Employers frequently ask the question, “When should I send an injured employee to Mount Auburn Occupation Health or to a hospital emergency department?”

The answer depends on the situation and the severity of the injured employee’s condition. When dealing with this issue, keep in mind a key point:

IF IN DOUBT WHETHER AN INJURY IS APPROPRIATE TO BE SENT TO MOUNT AUBURN OCCUPATION HEALTH OR THE EMERGENCY ROOM PLEASE CALL 617-354-0546

In non-emergency situations, there are a number of disadvantages to using the hospital emergency department.

 Hospital emergency department charges are considerably higher than those at Mount Auburn Occupation Health.

 Life and limb threatening emergencies take precedence over most work-related injuries. Your employees may, therefore, have an extended wait in the emergency department before being seen by a clinician.

 Managing work-related injuries requires close communication between the provider, the employee and the employer. Emergency departments are not set up to offer this level of communication.

 Emergency department physicians are generally not trained and experienced in managing work restrictions and facilitating return to work.

 Occupational health providers are trained to manage work-related injuries and illnesses. This results in significant cost savings for employers through reductions in both medical expenses and lost workdays. Reduced lost workdays means reduced indemnity costs for employers. Since both medical and indemnity costs are reduced, total case cost, and ultimately workers’ compensation insurance premiums, are reduced.

WC Info Booklet and Forms 14 Guidelines for Deciding the Most Appropriate Option for Care

Please call 1st if possible 617-354-0546 Monday – Friday 8:00 am – 4:30 pm

I. Conditions appropriate for treatment at Mount Auburn Occupation Health:  All musculoskeletal sprains and strains  Rashes or burns  Simple lacerations  Mild eye injuries, such as abrasions or foreign body  Possible fractures  Blood exposures  Repetitive strain injuries  Animal bites  Chemical exposures not causing life threatening symptoms (except eye exposures)

Please call 1st if possible 617-499-5025 24/7

II. Conditions appropriate for hospital emergency department treatment:  Complaints of chest pain  Injuries resulting in significant loss of blood (shock) or uncontrolled bleeding  Respiratory distress including shortness of breath resulting from allergic reactions (bee sting) and acute toxic exposures  Loss of consciousness  Obviously deformed fractures  Severe eye injuries: acid/base or other chemical splashes or sever direct trauma  Obviously abnormal mental status  Extensive or very deep injuries or lacerations  Electrical injuries (which may be more serious than they appear on the surface)  Chemical exposures causing life threatening symptoms

This is a partial list intended to respond to the most common questions from employers regarding triage.

WC Info Booklet and Forms 15