IOJ Employee Resource Packet

We want to ensure you receive the best care possible. This packet is designed to provide you with the information you need to navigate the IOJ process.

If you have any questions, please contact AFD Workers' Compensation: Monday - Friday 7:00AM - 3:30PM Office 512-974-1310 / Fax 512-974-4102 Email: [email protected] Location: 517 S. Pleasant Valley Rd, Austin 78741

WC RN: Dawn Pepe, MSN, RN WC Admin: Rocio Hernandez WC Admin: Jenni Garcia

SPECIAL INSTRUCTIONS FOR INJURED EMPLOYEE

Bring the following 5 forms to each of your medical visits: 1) TX Workers' Compensation Work Status Report (DWC Form 73) or Emergency Room Work Status Report for ER / Urgent Care visits 2) Essential Job Tasks and Descriptions - Operational Firefighter 3) Essential Job Tasks and Descriptions - Chief's Aide Light Duty 53-hour Assignment 4) Chief's Aide Qualification Checklist - In order to be considered for the Chief's Aide position, the Checklist must be completed and signed by your medical provider. 5) Essential Job Tasks and Descriptions - Light Duty 40-hour Assignment

Return completed forms immediately after your medical visit to: AFD Workers' Compensation via email [email protected] or fax 512-974-4102

If Released to Work with Restrictions (Light Duty): 1) Contact AFD WC immediately for further direction. Do not assume that you can just show up to shift without direction from AFD WC, the Return to Work process starts with the WC office. 2) Please make sure the Chief's Aide form is complete. This form is required to be considered for the Light Duty 53 hour program, otherwise the default is a 40 hour Assignment.

Wellness Center is closed Friday, Saturday, Sunday and all COA Holidays

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Steps of the IOJ Light Duty (aka Alternate Duty) Job Assignment Process:

 1st – Your Provider changes your work status to allow you to Return-to-Work with Restrictions.  2nd – Send your completed Work Status paperwork to the AFD Workers' Compensation Office immediately after seeing a Doctor or ER Visit. *Take pic with phone and email to [email protected] or Fax: 512-974-4102  3rd – Call AFD WC Team for your Light Duty Processing appointment AND call Wellness for an appt. with Dr. Parrish The Workers' Compensation Team is the central point of contact for all IOJ activity.  Telephone: 512-974-1310 / Fax 512-974-4102 WC Team: Rocio Hernandez, Jenni Garcia and Dawn Pepe, RN Operating Hours: Monday-Thursday 0700-1530 If released to Light Duty Saturday or Sunday, Call the WC Office Monday Morning.

 4th – Light Duty Intake Processing is with WC and Dr. Parrish/Wellness Center.

IOJ paperwork required by the WC Team to process your Light Duty assignment: 1. Work Status (DWC-73) Form or Emergency Room Work Status Report 2. Chief’s Aide Checklist Form 3. Physical Therapy prescribed plan (preferred, not required)

 5th – Complete intake paperwork and Bona Fide Offer of Light Duty Job Assignment at the WC Office.  6th – Medical Consultatio.n with Dr Parrish.  7th – Fitness evaluation by Wellness Fitness team. Your prescribed Physical Therapy plan will be reviewed, if applicable.  8th – Report to your Light Duty Job Assignment.  9th – Report to Physical Rehabilitation & Conditioning Program at the Wellness Center Gym 0730-0830.  Chief’s Aide Light Duty 53-Hour Firefighter reports at 0730, the morning ending their shift, when the shift ends on Monday, Tuesday, Wednesday, or Thursday (excluding CoA holidays).  Light Duty 40-Hour Firefighter reports at 0700, Monday through Thursday (excluding CoA holidays).

Change in your Work Restrictions or Duty Status:  1st – Your Provider changes your Work Restrictions.  2nd – Call the AFD WC office to determine if an appt. is required; Send updated Work Status Form (DWC-73 & Chief’s Aide Form, if applicable) to AFD WC Office.  3rd – Contact the Wellness Center to schedule a Medical Consultation with Dr. Parrish. Returning to Full Duty:  1st – Your Provider changes your Work Status to allow you to Return-to-Work without Restrictions.  2nd – Send updated Work Status Form to AFD Workers' Compensation Office.  3rd – Contact the Wellness Center to schedule a Return-to-Work Medical Consultation with Dr. Parrish. If you have been released by your Provider, you must also be seen by Dr. Parrish. • Note – If Dr. Parrish is unavailable to assess you before your next scheduled shift, you may return to work if cleared by WC Team, but you must be seen by Dr. Parrish at his next available opportunity.

 4th – Complete the Return-to-Work Fitness Consultation with Wellness Fitness team.  5th – Meet with Wellness Division Chief for exit review of the Physical Rehabilitation & Conditioning Program.  6th – Report to AFD Workers' Compensation Office to complete the injury process.

Austin Fire Department IOJ Employee Resource Packet – Rev. OCT19 AUSTIN FIRE DEPARTMENT WORKERS’ COMPENSATION

REGISTERED NURSE ADMINISTRATOR ADMINISTRATOR

Dawn Pepe Rocio Hernandez Jenni Garcia

Office Hours: Monday – Friday 7:00AM to 3:30PM [email protected] 512-974-1310 FIREFIGHTER YOU HAVE A DECISION TREE MEDICAL WORKERS AFD WC IS WORK-RELATED CARE INJURY INJURY-ON-JOB COMP CENTRAL POINT OF CONTACT FOR ALL IOJ AFD POLICY CAN YOU SAFELY WORK STATUS ACTIVITY REPORT TO COMPLETE PERFORM YOUR REPORT SUPERVISOR FROI DUTIES? YOU MUST A.S.A.P. SEND OR WITHIN IMMEDIATELY 24 HOURS FIREFIGHTER TO AFD WC WORK RESPONSIBILITY STATUS EMPLOYEE NO YES IF BLOOD OR SECTION AND DESCRIPTION DISEASE FULL OF INJURY NO EXPOSURE DUTY GO TO SEEKING CARE DUTY HOSPITAL ER ON YOUR OWN TRIAGE SUPERVISOR FOR TRAUMA, ANY PROVIDER CONFIRM CONTACT BC & SAFETY INFECTION OR WHO TAKES WC STATUS WITH AFD WC LOGS BILL COLL RESPONSIBILITY SERIOUS INSURANCE AFD WC TIMEKEEPING 512-978-0030 INJURY INJURY 512-422-3796 INVESTIGATION

SEEKING CARE MEDICAL LIGHT YOU WILL NEED AT WORK EVIDENCE DUTY A FULL DUTY EXPOSURE SUBMIT FROI RELEASE FROM YOUR CHOICE GET AS SOON 10 DAYS RECEIVE EMAIL YOUR OF WC FACILITY AS POSSIBLE TO GET WITH IOJ IN AUSTIN PROVIDER RESOURCE BC LOGS BASELINE TIMEKEEPING BLOOD TEST PACKET You will need to WORK STATUS WORK STATUS be released by REPORT REPORT Dr. Parrish CHIEF’S AIDE AFD WORKERS’ and Work Comp COMPENSATION YOU MUST GET YOU MUST GET LIGHT DUTY COMPLETED AT COMPLETED AT OPTION 53- 512-974-1310 FACILITY EACH MD VISIT HOUR WEEK [email protected] RR1 ³

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Austin Fire Department Emergency Room Work Status Report

EMPLOYEE: DOB: DOI: Date of Birth Date of Injury/Illness Nature of Injury Part(s) of Body Injured

PART I – WORK STATUS (Medical Provider completes this section. REFER TO ESSENTIAL JOB TASKS) Return to work without restrictions on:

Return to work with restrictions on: Restrictions must be detailed in Part II below Follow-up visit scheduled on: No follow-up required Patient not cleared for any type of work from: to Rationale: (AFD will accommodate most limited duty work restrictions)

PART II – RESTRICTIONS (Medical Provider completes this section. DESCRIBE LIMITATIONS)

PART III – TREATMENT PLAN (Medical Provider completes this section. DESCRIBE Treatment Plan plus PT &/or Testing to be Scheduled)

DATE MEDICAL PROVIDER PRINTED NAME

MEDICAL PROVIDER SIGNATURE

FacilityName Telephone

Address

City, State ZIP

SEND FORM TO AFD WORKER’S COMPENSATION OFFICE IMMEDIATELY Email to: [email protected] Fax to: 512-974-4102 Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Austin Fire Department

Essential Job Tasks and Descriptions, Operational Firefighter:

(1) Wearing personal protective ensemble (PPE) and SCBA, performing fire-fighting tasks (e.g., hose line operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue operations, and other emergency response actions under stressful conditions while wearing personal protective ensembles and self-contained breathing (SCBA), including working in extremely hot or cold environments for prolonged periods. (2) Wearing an SCBA, this involves a demand valve-type positive-pressure face piece or HEPA filter masks, which requires the ability to tolerate increased respiratory workloads. (3) Exposure to toxic fumes, irritants, particulates, biological (infectious) and non-biological hazards, and/or heated gases, despite the use of personal protective ensembles and SCBA. (4) Climbing six or more flights of stairs while wearing fire protective ensemble weighing at least 50lb (22.6kg) or more and carrying equipment/tools weighing an additional 20 to 40lb (9 to 18kg). (5) Wearing protective fire ensemble that is encapsulating and insulated, which will result in significant fluid loss that frequently progresses to clinical dehydration and can elevate core temperature to levels exceeding 102.2°F (39.9°C) (6) Wearing PPE and SCBA, searching, finding, and rescue-dragging or carrying victims ranging from newborns up to adults weighing over 200lb (90kg) to safety despite hazardous conditions and low visibility. (7) Wearing PPE and SCBA, advancing water-filled hose lines up to 2 ½” (65mm) in diameter from fire apparatus to occupancy [approximately 150ft (50m)], which can involve negotiating multiple flights of stairs, ladders, and other obstacles. (8) Wearing PPE and SCBA, climbing ladders, operating from heights, walking and crawling in the dark along narrow uneven surfaces, and operating in proximity to electrical power lines and/or other hazards. (9) Unpredictable emergency requirements for prolonged periods of extreme physical exertion without benefit of warm-up, scheduled rest periods, meals, access to medication(s), or hydration. (10) Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens. (11) Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments, including hot, dark, tightly enclosed spaces, which is further aggravated by fatigue, flashing lights, sirens, and other distractions. (12) Ability to communicate (give and comprehend verbal orders) while wearing personal protective ensembles and SCBA under conditions of high background noise, poor visibility, and drenching from hose lines and/or fixed protection systems (sprinklers). (13) Functioning as an integral component of a team, where sudden incapacitation of a member can result in mission failure or in risk of injury or death to civilians or other team members. A member, while wearing full protective clothing (turnout coat and pants, helmet, boots and gloves) and SCBA, is required to safely perform a variety of fire-fighting tasks that require upper body strength and aerobic capacity. For those not familiar with fire suppression, the following specific details inherent to the activities in essential job task are offered: (1) Lifting and carrying tools and equipment (e.g., axe, halligan tools, pike pole, chain saw, circular saw, rabbet tool, high- rise pack, and hose) that weight between 7 and 20lb (3.2 and 9kg) and are used in a chopping motion over the head, extended in front of the body, or in a push/pull motion. (2) Advancing a 1 ¾” (45mm) or a 2 ½” (65mm) diameter hose line, which requires lifting, carrying, and pulling of the hose at grade, below or above grade, or up ladders. In addition to the weight of the hose itself, a 50ft (15m) section of charged 1 ¾” (45mm) hose containing approximately 130lb (59kg) of water. (3) Performing forcible entry while utilizing tools and equipment (e.g., axe, halligan tool, chain saw, circular saw, or rabbet tool) that requires chopping, pulling, or operating these items to open doors, windows, or other barriers to gain access to victims or possible victims or to initiate fire-fighting operations. (4) Performing ventilation (horizontal or vertical) utilizing tools (e.g., axe, circular saw, chain saw, pike pole) while operating on a flat or pitched roof or operating off a ground or aerial ladder. This task requires the fire fighter to chop or push through roofs, walls or windows. Other tasks that could be performed can include search and rescue operations and other emergency response actions under stressful conditions, including working in extremely hot and cold environments for prolonged time periods.

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Austin Fire Department “Our Mission Goes Beyond Our Name”

4201 Ed Bluestein Blvd., Austin, TX 78721 www.CityofAustin.org/fire

Essential Job Tasks and Descriptions, Chief’s Aide:

(1) Shall be required to wear the approved Department uniform. No other portion of the protective ensemble shall be required to be worn (no turnouts, face piece, or SCBA).

(2) Must be able to work on a shift schedule (20-24 hours at a time).

(3) Shall assist the supervisor with clerical and delivery duties as needed throughout the shift period.

(4) Ability to board and exit a Department vehicle unassisted (light truck only).

(5) May drive a Department vehicle (light truck only) and shall respond code three (lights and sirens) during the shift period to emergency scenes and/or,

(6) May ride in a Department vehicle (light truck only) and shall respond code three (lights and sirens) during the shift period to emergency scenes.

(7) Ability to communicate (written and verbally) with supervisor and operate a portable or mobile radio upon request.

(8) While at emergency scenes, may assist the supervisor by taking notes, assisting with communications, or other clerical duties.

(9) Shall remain near the command post at an emergency scene with access to protection from the weather (cab of light truck) with the ability to change positions from seated to standing as necessary.

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Austin Fire Department “Our Mission Goes Beyond Our Name”

4201 Ed Bluestein Blvd., Austin, TX 78721 www.CityofAustin.org/fire

Chief's Aide Qualification Checklist

Firefighter Name: TXFR:

The City of Austin Fire Department accommodates light duty positions in both 40 hour and 53 hour work week positions. In order to qualify the Firefighter for the most appropriate limited duty position, please answer the following questions.

Is the Firefighter able to:

Yes No

☐ ☐ Work on a shift schedule (20-24 hours at a time).

☐ ☐ Board and exit a Department vehicle unassisted at an Emergency scene (light truck only).

☐ ☐ Walk up to 4 hours over a 24 hour shift. (Firefighter will have access to protection from the weather [cab of light truck] and will have the ability to change positions from seated to standing positions as necessary.)

☐ ☐ Drive a Department vehicle (light truck only) and shall respond code three (lights and sirens) during the shift period to emergency scenes.

☐ ☐ Ride in a Department vehicle (light truck only) and shall respond code three (Lights and sirens) during the shift period to emergency scenes.

☐ ☐ Communicate (written and verbally) and operate a portable or mobile radio.

Date:

Medical Provider Printed Name Medical Provider Signature

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Austin Fire Department “Our Mission Goes Beyond Our Name”

4201 Ed Bluestein, Austin, TX 78721 www.CityofAustin.org/fire

Essential Job Tasks and Descriptions, Light Duty 40 / Modified Duty Firefighter:

(1) Must wear the approved fire department uniform.

(2) Will not be required to wear any other portion of the protective ensemble such as turnouts, a face piece, or SCBA and will not be subject to emergency response.

(3) Must be able to work Monday thru Thursday from 0700 to 1700, which is a 40 hour work week.

(4) Work duties may include clerical (answering phones, operating office machines, filing, etc.) and/or delivery duties as needed which may include periods of standing or sitting as necessary.

(5) Without assistance must be able to drive, board, and exit a non-emergency response vehicle (light truck, van, car, or SUV).

(6) Must be able to communicate both written and verbally.

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 Optum PO Box 152539 Tampa, FL 33684-2539

MAKING IT EASY... TO GET WORKERS’ COMPENSATION PRESCRIPTIONS FILLED.

Optum has been chosen to manage your workers’ compensation pharmacy benefits for your employer or their insurer. Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please fill out the card based on the instructions below.

Injured Employee: If you need a prescription filled for a work-related injury or illness, go to an Optum Tmesys® network pharmacy. Give this temporary card to the pharmacist. The pharmacist will fill your prescription at low or no cost to you. If your workers’ compensation claim is accepted, you will Questions? Need Help? receive a more permanent pharmacy card in the mail. Please use that card for other work-related injury or illness prescriptions. 1-888-764-1284

Most pharmacies, including Walgreens, our preferred provider, and all major chains, are included in the network. To find a network pharmacy call 1-888-764-1284 or visit tmesys.com.

Attention Pharmacists: Enter RxBIN, RxPCN and GROUP. Member ID # format is the date of injury and SSN combined as follows: YYMMDD123456789.

Tmesys is the designated PBM for this patient. WORKERS’ COMPENSATION PRESCRIPTION DRUG PROGRAM Tmesys Pharmacy Help Desk York Risk Services Group/Sedgwick City of Austin - Fire Department CARRIER/TPA EMPLOYER 1-888-764-1284

NDC Envoy INJURED WORKER NAME RxBIN 004261 or 002538 Please provide directly to Pharmacist SOCIAL SECURITY NUMBER DATE OF INJURY (YYMMDD) RxPCN CAL or Envoy Acct. # GROUP YORKFF DISTRIBUTED BY (SIGNATURE) DATE Notice to Cardholder: Present this card to the pharmacy to receive medication for your work-related injury. To locate a pharmacy: tmesys.com.

NOTE: This First Fill card is only valid for your workers’ compensation injury or illness.

Employer: Immediately upon receiving notice of injury, fill in the information above and give this form to the employee.

The following entities comprise the Optum Workers Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers Compensation Services of Florida; Progressive Medical, LLC, dba Optum Workers Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers Com- pensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC, dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation Medical Services, collectively and individually referred as “Optum.” IMP14-1614-204-YORKFF AFD Workers’ Compensation Insurance Information

York Risk Services/Sedgwick – Third-Party Administrator for the City of Austin General Contact Information: For questions regarding treatment authorization, pharmacy authorization, and/or billing information:

Main Telephone (512) 427-2481 Fax (512) 427-2482 Adjuster Sue Boukercha (512) 427-2370 [email protected] Adjuster Barbara Sachse (512) 427-2417 [email protected] Supervisor Leticia Navarro (512) 427-2465 [email protected]

Resources your Medical Provider will need:

Send Medical Bills to: York Risk Services, Inc. PO Box 559006 Austin, TX 78755-9906 For Treatment or Procedure Pre-Authorization Request, contact CareWorks (formerly WellComp): • Telephone (800) 580-2273 • Fax (800) 580-3123

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 DWC-41

The DWC-41 form, on the next page, is a very important part of the Workers’ Compensation process. Please complete the form and fax or mail it – or fill it out online – to ensure the Texas Department of Insurance - Division of Workers’ Compensation (TDI-DWC) receives it as soon as possible.

If TDI-DWC does not receive your DWC-41 form within 1 year of your Date-of-Injury, you could potentially lose your right to income benefits related to your claim (ie. if you need surgery, you would not get WC pay for any lost time from work).

Please complete the DWC-41* and send to TDI-DWC as soon as possible!

*FYI – the AFD WC team will process your FROI and send you an email with the Carrier’s Claim Number. Please add it to the top right section of your DWC-41.

The DWC-41 details:

When a Firefighter reports an injury, York Risk Services notifies the Texas Department of Insurance – Department of Workers Compensation (TDI-DWC). TDI-DWC then snail-mails a DWC-41 (Employee’s Claim for Compensation for a Work-Related Injury or Occupational Disease) to the injured FF. The DWC-41 must be returned to TDI-DWC within one (1) year from the date of injury.

You have 3 options to submit the DWC-41:

1) Complete & submit the DWC-41 online at: https://txcomp.tdi.state.tx.us/TXCOMPWeb/notice/iec/SelectLanguage.jsp - (keep a screen shot of the “submit” acknowledgement)

2) Print the attached DWC-41 pdf and fax it to TDI-DWC at (512) 804-4378 – (keep copy of “fax sent” acknowledgement)

3) Print the attached DWC-41 pdf. Complete it and mail it to TDI-DWC’s address: (keep Return Receipt or Tracking delivery record)

Texas Department of Insurance Division of Workers’ Compensation Records Processing 7551 Metro Center Drive, Suite 100, MS-94 Austin, TX 78744-1609

Any questions, the TDI-DWC contact is (800) 252-7031, or for further info go to www.tdi.texas.gov

Please don’t wait – do yourself a favor and send your DWC-41 asap! Thank you! Texas Department Of Insurance , Division of Workers' Compensation Records Processing 7551 Metro Center Dr. Ste.100 • MS·94 Austin, TX 78744-1609 ('- Send the completed form to this address. (800) 252-7031 (512) 804-4378 fax www.tdi.texas.gov Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC Form-041) Claim for workers' compensation must be filed by the injured employee or by a person acting on the injured employee's behalf within one year of the date of injury or within one year from the date the injured employee knew or should have known the injury or disease may be work-related. I. INJURED EMPLOYEE INFORMATION Name (First, Middle, Last ) I Social Security Number I Date of birth (mm I dd I yyyy) Address (street. city/town. state, zip code, county, country)

Phone Number I E-Mail address I Sex LJMale OF em ale I Race Ethnicity 0White, not of Hispanic Origin D Black, not of Hispanic Origin 0Hispanic 0Asian or Pacific Islander Do you speak English? I IYes 0No If no, specifylanguage Marital status nMarried 0Widowed Oseparated 0Single 0Divorced Do you have an attorney or other representation? oYes 0No If yes, name of representative (mm/dd/yyyy) Have you returned to work? []Yes UNo I If returned to work, date returned I Work status LJRegular LJ Restricted Occupation at time of injury Date of hire (mm I dd I yyyy) (at the time of injury) Hired or recruited in Texas LJ Yes LJNo I Pre-tax wages $ LJhourly uweekly LJnonthly II. INJURY INFORMATION (mm yyyy) I am reporting an LJinjury or D occupationaldis ease of injury I dd I I Time of injury � First work day missed (mm I dd I yyyy) injury was reported to the employer (mm I dd I yyyy) Where did the injury occur? County State Country If accident occurred outside of Texas, on what date did you leave Texas? (mm/dd/yyyy) Witness(es) to the injury (list by name) Describe cause of injury or occupational disease, including how it is work related

Body part(s) affected by the injury If injury is the result of an occupational disease: 1. On what date was the employee last exposed to the cause of the occupational disease? (mm I dd I yyyy) 2. When did you first know occupational disease was work related? (mm I dd I yyyy) Ill. EMPLOYER INFORMATION (at the time of in"ury) Employer name Employer address (street, city/town,state, zip code, county, country)

Employer phone number , Su,.._.··-- name IV. DOCTOR INFORMATION Phone number Name of treating doctor I Address (street, city/town, state, zip code) Name of workers' compensation health care network, if any

Signature of injured employee or p9'rson filling out this form o-n-1iehB.1fOf10jul°ed emPloyee

Printed name of injured employee or person filling out form on behalf of injured employee

DWC041 Rev. 03/07 111 11111111111111 11111 Information about Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC Form-041)

A claim for Workers' Compensation benefits must be filed with the Division of Workers' Compensation (Division) by the injured employee (you), or by a person acting on the injured employee's (your) behalf within one year of the injury or within one year from the date you knew or should have known the injury or disease may be work related; UNLESS good cause exists for the failure to timely file a claim, or the employer or the employer's insurance carrier does not contest the claim.

Upon receipt of your completed DWC Form-041, or other notice of your injury, the Division will create a claim and establish a DWC claim number for you, and the Division will mail information regarding workers' compensation in Texas to you. The Division will also notify your employer and the employer's workers' compensation insurance carrier.

SPECIAL INSTRUCTIONS AND INFORMATION FOR COMPLETING THE DWC Form-041

General Instructions • Complete all boxes in the DWC Form-041. • If you have questions about completing this form, please call your local Division Field Office at 1-800-252-7031.

Injured Employee Information • Work Status information o If you have returned to your regular job and you are performing the same duties as you were before your injury, check the "Regular" box. o If you have been released to work with restrictions by a doctor, check "Restricted."

InjuryInformation • An iniury is damage to your body that was caused by a single incident, accident, or event. • An occupational disease is an illness or injury related to or caused by the work you do, and may include injuries to your body that are the result of repetitive activities you performed on the job over a period of time.

Employer Information • Provide information about your employer at the time you were injured.

Doctor Information • If you already have a workers' compensation treating doctor, provide the name and address of the doctor. • If you are covered under a workers' compensation healthcare network, provide the name of the network.

Contacting Texas Department of Insurance, Division of Workers' Compensation

If you have questions about filling out this form or workers' compensation in Texas, please call your local Division Field Office at 1-800-252-7031.

NOTE: With few exceptions, you are entitled, on request, to be informed about the information that the Division collects or maintains about you and your workers' compensation claim. Under §552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under §559.004 of the Texas Government Code you are entitled to have the Division correct information the Division creates about you or your workers' compensation claim that is incorrect. For more information, call the Division's Open Records section at 512-804-4437.

DWC041 Rev. 03/07 Instructions NOTICE TO EMPLOYEES CONCERNING WORKERS’ COMPENSATION IN TEXAS

COVERAGE: City of Austin has workers’ compensation insurance coverage from Self-Insured per Section 504 of the Texas Labor Code in the event of work-related injury or occupational disease. This coverage is effective from 03/13/2015. Any injuries or occupational diseases which occur on or after that date will be handled by York Risk Services Group. An employee or a person acting on the employee’s behalf, must notify the employer of an injury or occupational disease not later than the 30th day after the date on which the injury occurs or the date the employee knew or should have known of an occupational disease, unless the Texas Department of Insurance, Division of Workers’ Compensation (Division) determines that good cause existed for failure to provide timely notice. Your employer is required to provide you with coverage information, in writing, when you are hired or whenever the employer becomes, or ceases to be, covered by workers’ compensation insurance.

EMPLOYEE ASSISTANCE: The Division provides free information about how to file a workers’ compensation claim. Division staff will answer any questions you may have about workers’ compensation and process any requests for dispute resolution of a claim. You can obtain this assistance by contacting your local Division field office or by calling 1-800-252-7031. The Office of Injured Employee Counsel (OIEC) also provides free assistance to injured employees and will explain your rights and responsibilities under the Workers’ Compensation Act. You can obtain OIEC’s assistance by contacting an OIEC customer service representative in your local Division field office or by calling 1-866-EZE-OIEC (1-866-393-6432). SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact the Division at 1-800-452-9595.

Notice 6 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.101(e)(1)

NOTICE TO EMPLOYEES CONCERNING ASSISTANCE AVAILABLE IN THE WORKERS’ COMPENSATION SYSTEM FROM THE OFFICE OF INJURED EMPLOYEE COUNSEL

Have you been injured on the job? As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). OIEC is the state agency that assists unrepresented injured employees with their claim in the workers’ compensation system. You can contact OIEC by calling its toll-free telephone number: 1-866-EZE-OIEC (1-866-393-6432). More information about OIEC and its Ombudsman Program is available at the agency’s website (www.oiec.texas.gov). OMBUDSMAN PROGRAM WHAT IS AN OMBUDSMAN? An Ombudsman is an employee of OIEC who can assist you if you have a dispute with your employer’s insurance carrier. An Ombudsman’s assistance is free of charge. Each Ombudsman has a workers’ compensation adjuster's license and has completed a comprehensive training program designed specifically to assist you with your dispute. An Ombudsman can help you identify and develop the disputed issues in your case and attempt to resolve them. If the issues cannot be resolved, the Ombudsman can help you request a dispute resolution proceeding at the Texas Department of Insurance, Division of Workers’ Compensation. Once a proceeding is scheduled an Ombudsman can: • Help you prepare for the proceeding (Benefit Review Conference and/or Contested Case Hearing); • Attend the proceeding with you and communicate on your behalf; and • Assist you with an appeal or a response to an insurance carrier’s appeal, if necessary. OFFICE OF INJURED EMPLOYEE COUNSEL FIRST RESPONDER LIAISON

The Office of Injured Employee Counsel (OIEC) is the state agency that assists, educates, and advocates on behalf of the injured employees of Texas.

OIEC has a designated employee who is the liaison for first responders. The liaison is highly trained as an ombudsman and in the rights of first responders within the workers’ compensation system.

Yolanda Garcia FIRST (512) 804-4173 RESPONDER [email protected] LIAISON As a first responder, you can contact her directly for help with your workers’ compensation claim.

OIEC provides services in 21 offices across the state, with the central office located in Austin, Texas. Agency services include advocacy, customer service, and dispute assistance through OIEC’s Ombudsman Program.

CONNECT @OIEC @OIECtube oiec.texas.gov For general information you may also contact OIEC at [email protected] or (866) 393-6432 Office of Injured Employee Counsel Page 18 of 20 9/2017 AFD Employees – Workers Compensation & FMLA Information

If you suffer a serious health condition as a result of your employment with AFD, you may be covered under the federal Family and Medical Leave Act (FMLA) and state workers’ compensation laws.

FMLA leave may run concurrently with a workers’ compensation when the injury is one that meets the criteria for a “serious health condition” under the FMLA. You could receive workers’ compensation benefits to replace lost wages, while at the same time having health benefits maintained under the FMLA.

If you are receiving workers’ compensation benefits and on FMLA leave, you maintain the employee’s group health plan coverage as if you had not taken the leave. In addition, if you are under workers’ compensation absence as FMLA leave, then you are entitled to all employment benefits accrued prior to the date on which the leave commenced.

Should you wish to submit a request for leave under FMLA, you will need to turn in the following forms:

• Request for FMLA Leave Form (http://cityspace.ci.austin.tx.us/departments/hrm/forms/request- for-fmla-leave.docx) • Certification for Employee's Serious Health Condition (http://cityspace.ci.austin.tx.us/departments/hrm/forms/certification-for-employees-serious-health- condition.docx)

For more information, please see the following links:

• Employee Rights under the Family and Medical Leave Act (FMLA)- (https://www.dol.gov/whd/regs/compliance/posters/fmlaen.pdf) (attached) • Federal Policy (PDF) (https://www.dol.gov/whd/regs/compliance/whdfs28.pdf)

Contact Info :

Sandra Lopez, HR Advisor Email: [email protected] Phone: 512-974-1269 Fax: 512-974-4177

Austin Fire Department IOJ Employee Resource Packet – Rev. Oct19 [Type here] EMPLOYEE RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT THE DEPARTMENT OF LABOR WAGE AND HOUR DIVISION

LEAVE Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period ENTITLEMENTS for the following reasons: • The birth of a child or placement of a child for adoption or foster care; • To bond with a child (leave must be taken within 1 year of the child’s birth or placement); • To care for the employee’s spouse, child, or parent who has a qualifying serious health condition; • For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job; • For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse, child, or parent. An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.

An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule.

Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.

BENEFITS & While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave. PROTECTIONS Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions.

An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.

ELIGIBILITY An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must: REQUIREMENTS • Have worked for the employer for at least 12 months; • Have at least 1,250 hours of service in the 12 months before taking leave;* and • Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite. *Special “hours of service” requirements apply to airline flight crew employees.

REQUESTING Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice, LEAVE an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures. Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified.

Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required.

EMPLOYER Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the RESPONSIBILITIES employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.

Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave.

ENFORCEMENT Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit against an employer.

The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights.

For additional information or to file a complaint: 1-866-4-USWAGE (1-866-487-9243) TTY: 1-877-889-5627 www.dol.gov/whd U.S. Department of Labor Wage and Hour Division

WH1420 REV 04/16