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Workers Compensation

Instructions: 

1. All injuries must be reported to the site administrator, secretary or clerk immediately. 

2. Supply employee with Workers' Compensation forms (Injured employee is never allowed 

to take forms back to room or home. They are to be completed in the office when employee receives it.) 

3. Complete all forms in the packet: (Even if it is just a report of incident) 

     A. DWC1 - employee completes top portion; employer completes bottom portion

     B. Fill out the Employer's Report of Occupational Injury Illness

     C. Designation seeking treatment (Must be filled out correctly) example: If 

          employee is going to doctor they must mark: going to Workers Compensation Physician.

         If employee is not seeking care they must mark: Refusing care at this time.

     D. Acknowledgement for Employee Packet, Signed by employee

     E. Guidelines for Workers' Compensation Absences form, Signed by employee 

     F. Give employee Worker's Compensation work health services office address and hours, Third Party

         Administrator information, Medical Provider Network Pamphlet and copy of the DWC-1, notice of

         potential eligibility and Guidelines for Workers' Compensation Absences.

         (They are all marked Employee Copy) 

4. Call Company Nurse, 877-223-9307. This call must be made whether or not the 

employee is seeking treatment, as this will provide the necessary permission to be seen by a doctor, and generate the forms required by York Insurance. 

5. Call Lisa, 661-400-2928 (at any time during this process), to notify her that an employee has 

been injured. If you are unable to reach Lisa, please leave a message 

6. Send all forms immediately (A, B, C, D and E) to Lisa Shaaban at Support Service. 

7. It is critical to maintain a communication between the site secretaries and Lisa Shaaban as to 

the employee's work status at all times. Call Lisa Shaaban at Support Service Office at 661 400-2928 

8. In the event there is a 911 emergency immediately contact Lisa Shaaban (661-400-2928 

after contacting 911. Ms. Shaaban will take care of all above information for the employee.