Fillable Printable Supervisor's Injury or Illness Report - Pennsyvania

Supervisor's Injury or Illness Report - Pennsyvania

Carnegie Mellon University

Human Resources

Benefits & Compensation Office

5000 Forbes Avenue, 319 SCRG

Pittsburgh, PA 15213-3730

(412) 268-2047 | Fax: (412) 268-7472

WORKERS' COMPENSATION INFORMATION

In Pennsylvania, the workers' compensation law provides wage loss and medical benefits to

employees who cannot work, or who need medical care, because of a work-related injury.

Benefits are required to be paid by your employer when self-insured, or through insurance

provided by your employer. Your employer is required to post the name of the company

responsible for paying workers' compensation benefits at its primary place of business and at its

sites of employment in a prominent and easily accessible place, including, without limitation,

areas used for the treatment of injured employees or for the administration of first aid.

You should report immediately any injury or work-related illness to your employer.

Your benefits could be delayed or denied if you do not notify your employer immediately.

If your claim is denied by your employer, you have the right to request a hearing before a

workers' compensation judge.

The Bureau of Workers' Compensation cannot provide legal advice. However, you may contact

the Bureau of Workers' Compensation for additional general information at:

Bureau of Workers' Compensation

1171 South Cameron Street, Room 103

Harrisburg, Pennsylvania 17104-2501

Telephone number within Pennsylvania (800) 482-2383

Telephone number outside of this Commonwealth (717) 772-4447

TTY (800) 362-4228 (for hearing and speech impaired only)

www.state.pa.us - PA Keyword: workers comp.

ACKNOWLEDGMENT

I, ___________________________________________________________________________,

employee of ___________________________________________________________________,

hereby certify that I was provided with the above statement on ______/______/________ (date).

______________________________________________________________________________

Employee signature

ACKNOWLEDGMENT OF EMPLOYEE RIGHTS AND DUTIES UNDER SECTION 306

OF THE PENNSYLVANIA WORKERS' COMPENSATION ACT

1. All employees who are injured on the job and require medical treatment must treat with one of the health care providers

listed on their employers’ panel for a period of ninety (90) days. Should the employee not comply with the foregoing, the

employer will be relieved from liability for payment for the services rendered during such applicable period.

2. Employees faced with an immediate medical emergency may treat with the medical care provider of their choice.

However, subsequent treatment must be obtained from one of the employer's designated health care providers for the first

ninety (90) days from the date of first treatment by that designated provider.

3. Following expiration of the ninety (90) day treatment period, an employee may treat with a non-designated health care

provider so long as the employee provides notice of the change to his/her employer within five (5) days of the first visit to

that provider. Failure to provide such notice may relieve the employer of the obligation to pay for services rendered by the

non-designated provider. All health care providers must provide employers with an initial medical report ten (10) days

following the employee's first visit and on a monthly basis so long as treatment continues.

4. Both designated and non-designated physicians must accept as payment in full the amount due as calculated pursuant to

the provisions of the Act. No provider may charge or accept from an injured worker any greater amount, unless the

treatment was for an injury or illness not covered by the Workers' Compensation Act.

5. Employees who refuse reasonable medical treatment, including hospitalization, surgery, medication and/or supplies will

forfeit all rights to compensation or any increase in disability status resulting from such refusal.

6. Under the provisions of the Act, employers are required to provide injured employees with reasonable hospital and

physician services, medicine, supplies, or orthopedic appliances and prosthesis. If a prosthesis is required, the employer

will provide for training for use of the prosthesis as well as replacement prosthesis. Continuing medical care if prescribed

by a physician will also be covered, regardless of whether loss of earning power occurs.

7. If hospitalization is required as a result of a work-related injury, the employer will pay for semi-private room. Cost for a

private room will be covered only in the event a semi-private room is not available.

8. Should invasive surgery be prescribed by an employer-designated provider, the employee shall be permitted to obtain a

second opinion from a provider of the employee's own choice, at the expense of the insurer. If the second opinion differs

from the opinion of the employer-designated provider, the employee may choose which course of treatment to follow

provided the second opinion provides a specific and detailed course of treatment. However, if the employee chooses to

follow the procedures designated in the second opinion, such procedures shall be performed by one of the employer's

designated providers for a period of ninety (90) days from the date of the visit to the provider of the employee's choice.

This is a summary of some of your rights and duties under the Workers' Compensation Law of Pennsylvania. Questions

concerning the above described rights and duties under Section 306 may be directed to the Pennsylvania Bureau of Workers'

Compensation Help Line at 1-800-482-2383 or (717) 772-4447.

EMPLOYEE:

I HAVE READ THE ABOVE AND UNDERSTAND MY RIGHTS AND RESPONSIBILITIES.

EMPLOYEE PRINT NAME: ________________________________________________________________________

SIGN NAME _________________________________________________________ DATE______________________

SUPERVISOR:

IF THE EMPLOYEE IS UNABLE OR REFUSES TO SIGN, IT IS ACKNOWLEDGED THAT THE EMPLOYEE WAS

PROVIDED A COPY OF THIS DOCUMENT.

SUPERVISOR PRINT NAME: ______________________________________________________________________

SIGN NAME _________________________________________________________ DATE _____________________

Send copy to the Benefits Office. Employee should also retain a copy. Revised 09/2004

Supervisor’s Injury/Illness Report

ATTENTION: This form contains information relating to employee health and must be used in a manner that

protects the confidentiality of employees to the extent possible while the information is being used for

occupational safety and health purposes.

This Injury/Illness Report is one of the first forms you must fill out when a recordable work-related injury or illness

has occurred. Together with other documents, these forms help the University and OSHA develop a picture of the

extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you

must fill out this form. According to Public Law 91-596 and 29 CFR 1904, OSHA's record-keeping rule, you must

keep this form on file for 5 years following the year to which it pertains.

Completed by:

Title: If you need additional copies of

Phone:

this form, you may photocopy

Fax:

and use as many as you need.

Date:

Case number from the Log (to be completed by HR)

Œ Employee / Working Student Information

Please print or type clearly

Last Name, First Name, M.I. r Male r Female

Status:

r Employee

r Working student

Job Title

Department Work Phone

Date of Birth Social Security Number

Normal Starting Time ____________ AM or PM

Normal Quitting Time ____________ AM or PM

Date of Hire

(leave blank if unknown)

Home Address: Street

City County of Residence

State

Zip Code Home Phone

Supervisor’s Name

Supervisor’s Phone Date supervisor was first

made aware of injury/ illness

• Description of Incident

Date of injury/illness:

Time employee began work: _______________________ AM or PM

Time of event: ________________________ AM or PM

r Check if time cannot be determined.

Was Security notified?

r Yes r No

Where did injury/illness occur? (List specific location, i.e. Wean Hall in front of elevator; Baker Hall stairwell, 2nd landing):

Supervisor’s Injury/Illness Report, p. 2

What had the employee been doing just before the injury/illness resulted? (Be specific about equipment and activities,

i.e. walking down steps, heating sulfur with open flame for chemistry experiment; slicing lunch meat with electric slicer)

What happened? How did the injury occur? (i.e. ladder slipped on wet floor and employee fell 20 feet; hand slipped and finger

went into meat slicer, beaker broke and plume of smoke went into face)

What object or substance directly harmed the employee? (i.e. concrete floor, meat slicer blade, chlorine)

Did individual receive supervised training for the type of work

being performed?

r Yes r No

If yes, by whom and when?

How can this type of injury/illness be avoided in the future?

If there was a witness(es) to the incident, please list name(s) and telephone number(s)

Ž Description of Treatment

Was injured employee treated?

r Yes r No

Date treatment was received:

Name of treating physician or other health care professional:

Was employee treated in an

emergency room?

r Yes r No

Was employee hospitalized

overnight as an in-patient?

r Yes r No

Where was treatment given (at worksite or health care facility name and address) – leave blank if unknown.

Nature of injury (sprain, bruise, inhalation of chemicals, etc.)

Specific part of body injured (i.e. left index finger, right knee)

Is/was employee away from work as a

result?

r Yes r No

Last date worked: ________________________________________________

Last day paid in full: _______________________________________________

Date returned to work: _____________________________________________

Number of days missed (Write ‘0’ for none): ____________________________

If the employee died, when did death occur? Date: __________________________________________

• Signatures

________________________________________________ ________________

Injured’s Signature Date

________________________________________________ ________________

Supervisor’s Signature Date

White: HR-Benefits, 319 SCRG; Yellow: Environmental Health & Safety, FMS Bldg; Pink: Employee’s Department.

If you used a photocopied or downloaded form, please forward a copy of the completed form to each destination listed above.

Questions about reporting a work-related injury or illness? Contact the Benefits Office at 412-268-2047. Rev ised 01/02

NOTICE TO EMPLOYEES

CARNEGIE MELLON UNIVERSITY

HAS PROVIDED FOR THE PAYMENT OF BENEFITS UNDER THE

PENNSYLVANIA WORKERS’ COMPENSATION ACT

Any employee injured at work should report immediately to his/her supervisor.

IN THE CASE OF WORK-RELATED INJURY:

A. If you suffer a work-related injury, your employer or its insurance company must pay for reasonable surgical

and medical services and supplies.

B. To insure that your employer will pay for medical treatment, you must select one of the below-listed

physicians for medical treatment. For a life threatening emergency, report to UPMC-Shadyside Hospital’s

Emer gency Depa rt men t or the nearest hospital.

C. To ensure that your employer or the insurance company will pay for your follow-up medical treatment, you

must select one of the below-listed physicians or practitioners of the healing arts. To schedule an

appointment please call the designated phone numbers.

Doctor: CONCENTRA Medical Center Phone: 412-621-5430

Address: 120 Lytton Avenue, Suite 275, Pittsburgh, PA 15213

Doctor: Emergency Medicine Physician Phone: 412-623-2063

Address: UPMC Shadyside Hospital, 5230 Centre Ave., Pittsburgh, PA 15232

Doctor: Tri-State Orthopedics & Sports Medicine Phone: 412-696-0300

Address: 300 Chapel Harbor Dr., Suite 300, Pittsburgh, PA 15238

Doctor: Rehabilitation & Pain Specialists Phone: 412-963-6480

(Paul S. Lieber M.D. and Marc J. Adelsheimer M.D.)

Address: 5200 Centre Ave., Suite 612, Pittsburgh, PA 15232

Doctor: Neurosurgery Group of Western Pennsylvania Phone: 412-321-3033

Address: 420 E. North Ave., Suite 302, Pittsburgh, PA 15212

Doctor: Brett W. Carothers, D.C. (Chiropractic Medicine) Phone: 412-374-1400

Address: 218 Center Road, Monroeville, PA 15146

D. If you need ongoing treatment, you must receive treatment from one of the physicians listed for ninety (90)

days from the date of your first visit.

E. After this ninety (90) day period, if you still need treatment, you may choose to go to another licensed

physician or practitioner of the healing arts for treatment. You must notify the Benefits Office (Phone:

412-268-2047) of this action within five (5) days of your visit to the practitioner of your choice.

F. If one of the physicians listed above refers you to another licensed specialist, your employer or their insurer

will pay the bill for these services if the treatment is related to the work-related condition or injury.

G. Remember, it is important to tell your employer about your injury immediately!