Austin Fire Department IOJ Employee Resource Packet

We want to ensure you receive the best care possible.

This packet includes: AFD Policy E110.3, City of Austin Introduction, City of Austin Benefits Related to Workers' Comp, FMLA, Workers' Comp Insurance Information, Texas Department of Insurance DWC-41 form, Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System, Office of Injured Employee Counsel First Responder Liaison, and Texas Department of Insurance Return to Work Checklist.

If you have any questions, please contact AFD Workers' Compensation:

Office Tel: 512-974-1310 / Fax: 512-974-4102 Email: [email protected] Location: 517 S. Pleasant Valley Rd, Austin 78741

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SPECIAL INSTRUCTIONS FOR INJURED EMPLOYEE

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¾ If applicable, 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.

¾ Return completed forms immediately after your medical visit to AFD WC via email or fax.

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Austin Fire Department IOJ Employee Resource Packet – Rev. 2020 CITY OF AUSTIN WORKERS’ COMPENSATION

INTRODUCTION

The City of Austin is committed to providing Workers’ Compensation benefits in accordance with the regulations set forth in the Texas Workers’ Compensation Act and Rules. The Texas Workers’ Compensation system has established rights and responsibilities for employees who are injured on-the- job or whose illness is work-related. The following information is intended to give you an overview about these benefits. For questions or further assistance, contact your Departmental Workers’ Compensation Representative, Austin Fire Workers' Compensation Team, (Name) at 517 S. Pleasant Valley Rd, Austin, TX 78741, phone no. (512) 974-1310. (Department Location)

Your Workers’ Compensation Benefit: x Is provided for on-the-job injuries/illnesses that are deemed compensable x Replaces a part of your wages while losing time from work x Begins to accrue on the 8th day of lost time x Is paid to you at a rate of: i 70% of your average weekly wage (AWW) up to the maximum amount set by law x Average Weekly Wage is based on the actual wages you earned during the 13 weeks prior to the injury x Is provided on a non-City check and is known as a Temporary Income Benefit (TIBs) x TIBs will stop when you return to work at pre-injury wages or Maximum Medical Improvement (MMI) is reached x Covers reasonable and necessary medical treatment related to the injury/illness

Resources/Contacts x The City contracts with a Third Party Administrator, Sedgwick. Sedgwick sends the Workers’ Compensation TIBs checks to eligible employees and pays reasonable/necessary costs such as doctor visits, prescribed medicine, and prescribed medical equipment for claims accepted as compensable. x If you have questions about your claim, talk to your Departmental Workers’ Compensation Representative or contact Sedgwick at 512-427-2481. x The Human Resources Department’s Risk Management staff is also available at 512-974-3400 to answer your Workers’ Compensation questions.

HRD/Risk Management Employee’s Workers’ Compensation Packet 2016 Page 2 of 5

Risk Management: Workers’ Compensation Vol.5 - Revised 5/1/17 Page 82 of 95 General Order AUSTIN FIRE DEPARTMENT Number

Policy and Procedure E110.3 Subject: Effective Date: Rescinds: 12/13/2018 E110.2 On-the-Job Injury/Illness Page: 1 of 7

Application: Authorized by:

All AFD Personnel Joel G. Baker, Fire Chief

I. Purpose

To establish guidelines for the proper documentation and investigation of the occurrence of on-the-job injury or illness and to provide information regarding workers’ compensation benefits to members.

II. Policy

The injured member’s Battalion Chief/Section Supervisor shall be responsible for the investigation of any on the job injury or illness to include the completion of all required documentation.

A Safety Chief may be contacted by the investigating Battalion Chief/Section Supervisor for assistance with completing this process.

III. Procedure

A. When any member is injured on the job, or thinks they have been injured, regardless of whether or not they are planning on seeking medical treatment, they shall immediately notify their immediate supervisor.

B. For injuries occurring while on the scene of an emergency response, the member’s immediate supervisor shall contact Command and notify them of the injury. As the incident allows, Command will then notify Fire Dispatch and request that an injury page be sent. The incident number for the emergency response will be used for the injury documentation and Command will be responsible for ensuring that the casualty module is completed within RMS.

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 2 of 7

C. If the injury is not associated with an emergency response (Example: an injury that occurs at the station), the member’s supervisor shall immediately notify Fire Dispatch and request that an injury page be initiated. Fire Dispatch will generate an IOJ-INV call type and assign the affected member’s unit (if applicable) and the member’s Battalion Chief/Section Supervisor to the response. The Company Officer and the member’s Battalion Chief shall coordinate to determine if the unit can be returned to service with reduced staffing, based upon the nature and severity of the injury.

D. If the member’s Battalion Chief/Section Supervisor is not available for response, another Battalion Chief shall be assigned to the call. The injured member’s immediate supervisor shall be responsible for ensuring that an incident report is completed, along with the casualty module, within RMS.

E. When a member believes that they may have suffered an exposure to a contaminant or contagion, this same process shall be followed. See AFD General Order B311, Haz-Mat Incident Response Roster and Exposure Reports for additional information regarding this topic.

F. Although the member may decide not to seek medical evaluation and treatment, it is strongly encouraged and should be sought immediately as many injuries may worsen with a delay in treatment. Additionally, a delay in seeking medical treatment may produce a negative outcome with regard to the overall success of the member’s workers’ compensation claim. Ideally, the member’s Battalion Chief/Section Supervisor or the Safety Chief should provide transportation to the medical facility if transport by ambulance is not required.

G. If the member’s Battalion Chief/Section Supervisor transports the member, the member’s Battalion Chief/Section Supervisor, in coordination with the injured member, shall complete the First Report of Injury (FROI) form. The FROI form is only available on the Battalion Chief level iPad devices.

H. If the injury is very minor and the member declines immediate medical treatment, the member’s Battalion Chief or the Safety Chief shall complete the FROI as a “precautionary report” and will be submitted to the Workers’ Compensation Office.

I. Regardless of the decision to seek or not to seek medical treatment, the member’s Battalion Chief/Section Supervisor must be notified and shall respond to the member’s location to properly document and investigate the cause of the injury. The member’s immediate supervisor, Battalion Chief/Section Supervisor, and Safety Chief may coordinate to determine whether or not the injury warrants an immediate response. Photographs will be taken and included in the report, noting the location where the injury occurred, the actual mechanism of injury, as well as any other pertinent or relevant

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 3 of 7

findings. The investigation shall endeavor to identify the cause of the injury as well as provide an intervention or remediation plan to prevent further occurrences of injury.

J. The FROI form will automatically, as part of the design of the application, email a copy of the form to the member, the Safety Chief, and the Workers’ Compensation Group.

K. If the member declines medical treatment and cannot perform their assigned duties, they must request personal leave time as only a medical provider can place the member off duty (in a no-duty status) for an injury that occurs on-the- job. The member shall be informed that this action may cause the workers’ compensation to be automatically denied. Within this policy, the term “medical provider” is defined as a medical professional who is licensed and approved to treat workers’ compensation injury claims.

L. If the member decides to seek medical treatment at some later date/time, they must notify the AFD Workers’ Compensation group immediately. This contact can be made via email at: [email protected] or by phone at 512- 974-1310.

M. Any member who receives treatment by a medical provider for an on-the-job injury shall also:

1. Submit a completed Texas Workers’ Compensation Work Status Report Form 73 (DWC73) or, the Emergency Room Work Status Report Form, within 24 hours following each medical provider’s visit. This form will be supplied to the member upon submission of the FROI via email, within the IOJ Employee Resource Packet.

2. Retain the responsibility for ensuring that the medical provider completes and signs the DWC73 prior to submitting it to the Workers’ Compensation Group. The member must ensure that the medical provider checks the appropriate box on the DWC73 to indicate the return to work (or no work) status and indicate the effective date. If restrictions to duty are indicated, the medical provider must document these on the DWC73.

3. Provide the medical provider with a copy of the “Essential Job Tasks” for both Firefighter and Chief’s Aide, as well as the Chief’s Aide Qualification Checklist (all provided within the IOJ Employee Resource Packet).

4. Notify their Battalion Chief/Section Supervisor of any changes to their work status. Operations members shall report all status changes prior to 1000 hours on the day of their assigned shift. Staff members shall notify their

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 4 of 7

supervisor prior to the time they would normally arrive at their worksite.

5. On subsequent visits, ensure that the medical provider completes all necessary parts of the DWC73 form including and work status change, treatment plan, or physical therapy.

N. Failure to comply with M. (1) – Submitting Work Status Report Form 73 (DWC73) or, the Emergency Room Work Status Report Form after initial treatment AND after each medical care visit, immediately following or within 24 hours of the visit will result in the Workers’ Compensation Group notifying the employees immediate Supervisor/Section Supervisor and Battalion Chief. If non-compliance continues, the Division Chief may be informed as well as Payroll and the Third Party Administrator, which could affect Temporary Income Benefits and the employees Workers’ Compensation Line of Duty hours.

O. If, during the initial visit, the member is cleared for full duty by the medical provider, the member only needs to ensure that the Workers’ Compensation Group has acknowledged the receipt of the required documentation of their duty status (DWC73) change, immediately following their visit with the medical provider.

P. Members shall not be cleared for full duty status, regardless of their medical provider’s recommendation, while wearing any type of appliance, cast, or brace. Members shall also not be returned to full duty status with any stitched, stapled, or glued laceration or avulsion or any other type of wound that is deemed non-conducive to Operations Firefighting.

Q. If at any time the member is placed on a no duty status, the member, the member’s Battalion Chief, or the Safety Chief must turn in the DWC73 immediately to the Workers’ Compensation Group, following the medical provider’s visit and advise the member’s Battalion Chief or section supervisor of the member’s duty status. No other action is required of the member unless a change in their duty status occurs, or they are contacted by the Workers’ Compensation group.

R. If the medical provider placed any duty restrictions on the member, the member shall report to the Wellness Center for evaluation and consideration of a light duty assignment on the first regular business day (Monday through Thursday) following their medical provider’s visit. The member shall report at 0700 hours.

S. If approved for light duty, the member shall be provided with a Bona Fide Job Offer document. If the job offer is accepted, the form will be signed and the member will be offered one of the following two possible job assignments:

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 5 of 7

1. Chief’s Aide (available for Operations Division assigned members only):

a. Members who qualify to work as a Chief’s Aide shall normally be assigned to an Operations Battalion Chief or Division Chief on their regularly assigned shift. While most often the member will be assigned within their own chain of command (i.e. to their respective Battalion Chief), other possible assignments may include any other Battalion Chief within other battalions, the Safety Chief, the Shift Commander, and the Field Training Officer on their same shift. The Risk Management Division Chief will confer with the appropriate Shift Commander to determine the assignment of a Chief’s Aide.

b. Chief’s Aides will be assigned to a reduced work hour schedule (see below), and will participate in mandatory physical conditioning (see below). The reduced work schedule will allow for the use of line of duty leave (LDL) hours which is a requirement of the program. The assigned Battalion Chief will be responsible for accounting for time worked by the Chief’s Aide within the timekeeping system, per the instructions provided by the Risk Management Division Chief.

c. Chief’s Aides will report for their shift at the assigned duty station as an aide at 1030 hours. The member shall only perform assigned duties that are consistent with their particular physical abilities and restrictions, within their specific knowledge and skill set.

d. Chief’s Aides who report to work for their respective shifts, Sunday through Wednesday, shall also report to the Wellness Center, Monday through Thursday mornings for a mandatory physical rehabilitation and work conditioning program beginning at 0730 hours (only on the days that they are scheduled for their assigned shifts, at the end of the shift). Each physical rehabilitation and conditioning session will last approximately one hour and will be tailored to the member’s particular physical abilities and restrictions.

e. Once the Chief’s Aide has completed the physical rehabilitation and conditioning program session, they will be off duty for the remainder of the shift. The remaining days of the week, members shall also be off duty beginning at 0830. If possible, members should endeavor to schedule follow-up appointments and any other required rehabilitation sessions with their medical provider during this time; 0830-1030 hours.

f. A member shall continue to be scheduled for their normal Kelly Day shifts while assigned as a Chief’s Aide.

g. A member is not eligible to work any added time while assigned as a

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 6 of 7 Chief’s Aide. The only exception to this would be if the Chief’s Aide earned relief added time due to being assigned to an incident.

h. This schedule shall continue unless the member’s duty status changes.

2. Light Duty 40 (available to all members)

a. Members assigned to staff locations or those who are normally assigned to an Operations Division assignment but have been determined to not be able to safely perform the essential job tasks of a Chief’s Aide shall be assigned to a reduced workhours position (Light Duty 40) by the Risk Management Division Chief. The required schedule for the member shall be Monday through Thursday from 0700 hours to 1700 hours each day with no exceptions or variation, excluding holidays. Members will be required to use exception vacation hours for any holidays that are observed during their assigned workdays.

b. Members working Light Duty 40 positions are required to report to Wellness, Monday through Thursday at 0700 hours, for a physical rehabilitation and work conditioning program session. After completing the session, members shall report to their light duty assignment.

c. Members and supervisors will be provided with information on how to enter work time for a Light Duty 40 member along with an appropriate timesheet. This will be sent via email to the supervisor upon initial assignment.

d. During weeks which members were scheduled for their Kelly Day (only for members normally assigned to the Operations Division), they shall continue to be scheduled for a Kelly day. This will result in a variation to the member’s workweek with specific instructions on how to schedule and record the time being provided to the member’s Light Duty 40 supervisor.

e. The member is not eligible to work any added time while assigned to a Light Duty 40 position.

f. This schedule shall continue unless the member’s duty status changes.

T. If the member refuses the Bona Fide Job Offer for either of these two assignments, they shall sign the document, acknowledging their refusal of the offer and will be required to use their own personal leave until they return to full duty status (leave usage must with comply with current Department Leave Policy E103). The member shall also not be eligible for added time and will not receive partial temporary income benefits through workers’ compensation.

Policies and Procedures On-the-Job Injury/Illness E110.3, Page 7 of 7

U. If, after refusing the Bona Fide Job Offer, the member decides to reconsider accepting the Bona Fide Job Offer, they must contact the Workers’ Compensation Office.

V. Fraud – The Texas Labor Code-Workers’ Compensation Act; Texas Penal Code and the Texas Insurance Code each have sections outlining the Criminal Penalties associated with Insurance Fraud. Any employee who suspects workers’ compensation fraud should notify his or her Supervisor/Battalion Chief immediately. Supervisors/Battalion Chiefs who receive information about suspected workers’ compensation fraud must report that information to the Workers’ Compensation Group. 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. 05Dec18 [Type here] EMPLOYEE RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT THE UNITED STATES 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 AFD Workers’ Compensation Insurance Information

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: Sedgwick 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. 07FEB19 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 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 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 of Injured Employee Rights and Responsibilities in the Texas Workers’ Compensation System

As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). This assistance is offered at local offices across the State. These local offices also provide other workers’ compensation system services from the Texas Department of Insurance (TDI). TDI is the State agency that administers and regulates the workers’ compensation system through the Division of Workers’ Compensation (DWC).

Many services provided by OIEC and DWC can be completed over the telephone. You can contact OIEC by calling the toll-free telephone number 1-866-EZE-OIEC (1-866-393-6432). Additional information, including office locations, is available on the Internet at: www.oiec.texas.gov. You can contact DWC by calling the toll-free telephone number 1-800- 252-7031. Information about DWC is available on the Internet at: www.tdi.texas.gov.

Your Rights in the Texas Workers’ Compensation System:

1. You have the right to hire an attorney to help you with your workers’ compensation claim. For assistance locating an attorney, contact the State Bar of Texas’ lawyer referral service at 1-877-983-9227 or http://www.texasbar.com/. Attorney referral information can also be found on OIEC’s website at www.oiec.texas.gov.

2. You have the right to receive assistance from OIEC if you do not have an attorney. OIEC Customer Service Representatives and Ombudsmen are available to answer your questions and provide assistance with your workers’ compensation claim by calling OIEC or visiting an OIEC office. You must sign a written authorization before an OIEC employee can access information on your claim. Call or visit an OIEC office to fill out the written authorization. Customer Service Representatives and Ombudsmen are trained in the field of workers’ compensation and can help you with scheduling a dispute resolution proceeding about your workers’ compensation claim. An Ombudsman can also assist you at a benefit review conference (BRC), contested case hearing (CCH), and an appeal. However, Ombudsmen cannot make decisions for you or give legal advice.

3. You may have the right to receive medical and income benefits regardless of who was at fault for your injury, with certain exceptions. Your beneficiaries may be entitled to death and burial benefits. Information about the exceptions can be found at www.tdi.texas.gov or by visiting with OIEC staff.

4. You may have the right to receive medical care to treat your workplace injury or illness for as long as it is medically necessary and related to the workplace injury. You may have the right to reimbursement of your incurred expenses after traveling to attend a medical appointment or required medical examination if the trip meets qualifying conditions.

5. You may have the right to receive income benefits for your work-related injury. There are several types of income benefits and eligibility requirements. Information on the types of income benefits that may be available and the eligibility requirements can be found at www.tdi.texas.gov or by visiting with OIEC staff.

6. You may have the right to dispute resolution regarding income and medical benefits. You may request Medical Dispute Resolution if you disagree with the insurance carrier regarding medical benefits. You may request Indemnity (Income) Dispute Resolution if you disagree with the insurance carrier regarding income benefits. The law provides that your dispute proceedings will be held within 75 miles from your residence.

7. You have the right to choose a treating doctor. If you are in a Workers’ Compensation Health Care Network (network), you must choose your doctor from the network’s treating doctor list. You may change your treating doctor once without network approval. If you are not in a network, you may initially choose any doctor who is willing to treat your workers’ compensation injury; however,

Risk Management: Workers’ Compensation Procedures Vol.5 - Revised 5/1/17 Page 86 of 95 changing your treating doctor must be pre-approved by the DWC if you are not in a network. If you are employed by a political subdivision (e.g. city, county, school district,) you must follow its rules for choosing a treating doctor. It is important to follow all the rules in the workers’ compensation system. If you do not follow these rules, you may be held responsible for payment of medical bills. OIEC staff can help you to understand these rules.

8. You have the right for your workers’ compensation claim information to be kept confidential. In most cases, the contents of your claim file cannot be obtained by others. Some parties have a right to know what is in your claim file, such as your employer or your employer’s insurance carrier. Also, an employer that is considering hiring you may get limited information about your claim from DWC.

Your Responsibilities in the Texas Workers’ Compensation System

1. You have the responsibility to tell your employer if you have been injured at work while performing the duties of your job. You must tell your employer within 30 days of the date you were injured or first knew your injury or illness might be work-related.

2. You have the responsibility to know if you are in a Workers’ Compensation Health Care Network (network). If you do not know whether you are in a network, ask the employer you worked for at the time of your injury. If you are in a network, you have the responsibility to follow the network rules. If there is something you do not understand, ask your employer or call OIEC. If you would like to file a complaint about a network, call TDI’s Customer Help Line at 1-800-252-3439 or file a complaint online at http://www.tdi.texas.gov/consumer/complfrm.html#wc.

3. If you worked for a political subdivision (e.g., city, county, school district) at the time of your injury, you have the responsibility to find out how to receive medical treatment. Your employer should be able to provide you with the information you will need in order to determine which health care providers can treat you for your workplace injury.

4. You have the responsibility to tell your doctor how you were injured and whether the injury is work-related.

5. You have the responsibility to send a completed Employee’s Claim for Compensation for a Work-Related Injury or Occupational Claim Form (DWC041) to DWC. You have one year to send the form after you were injured or first knew that your illness might be work-related. Send the completed DWC041 form even if you already are receiving benefits. You may lose your right to benefits if you do not timely send the completed claim form to DWC. For a copy of the DWC041 form you may contact DWC or OIEC.

6. You have the responsibility to provide your current address, telephone number, and employer information to DWC and the insurance carrier. DWC can be contacted at 1-800-252-7031.

7. You have the responsibility to tell DWC and the insurance carrier anytime there is a change in your employment status or wages. (Examples of changes include: you stop working because of your injury; you start working; or you are offered a job).

8. Eligible beneficiaries or persons seeking death and burial benefits have the responsibility to send a completed Beneficiary Claim for Death Benefits (DWC-042) to DWC within one year following the employee’s date of death.

9. You are prohibited from making frivolous or fraudulent claims or demands.

Risk Management: Workers’ Compensation Procedures Vol.5 - Revised 5/1/17 Page 87 of 95 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

Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Dr., Ste. 100 Austin, TX 78744-1645

Return-to-work checklist

One of the main goals of the workers’ compensation system is to help you return to work as soon as possible after your work-related injury. During your recovery, staying active and continuing to follow your doctor’s instructions will help you heal faster. Use this checklist to help you stay at work or return to work.

Your doctor

Give your doctor this information: o Your workers’ compensation insurance carrier’s name and your claim number. If you do not have this information, ask your employer for it. o The Division of Workers’ Compensation’s (DWC) claim number. o Your workers’ compensation insurance adjuster’s name and phone number. If you don’t have this information, ask your employer for it. o Your employer’s name, address, and phone number where you work. Go to all of your medical appointments. Tell your doctor about the activities you do at your job. Make sure you understand what tasks, functions, and activities you can and can’t do while you heal. Follow your doctor’s instructions.

Your employer

Talk to your employer about whether there is work you can do while you recover. Give your employer your doctor’s name and phone number. Follow your employer’s rules about work-related injuries. Talk to your employer often about your recovery and the kinds of work you can do. The insurance carrier

Give the insurance carrier or adjuster your address and phone number. Call the insurance carrier or adjuster if your ability to work or your pay changes.

If you have questions, call DWC customer service at 1-800-252-7031, Monday to Friday, 8 a.m. to 5 p.m. Central time.

Last revised 08/2018