WORKERS COMPENSATION & RISK INSURANCE
- Work Related Injuries - What To Do
- Workers Compensation - Modified Duty
- Automotive Liability
- All Workers Compensation & Risk Insurace Forms
- Risk Insurance Forms
- Frequently Asked Questions
1. Work Related Injuries - What To Do
- Report the injury or occupational disease to your supervisory immediately.
- If an Employee requires treatment for a life-threatening condition; they may go to, or be transported to, the nearest medical facility. At Missouri S&T that would be Phelps County Regional Medical Center, ER.
- For non-life threatening conditions; the employee's supervisor must fill out a Workers Compensation Physician Referral (Missouri S&T 245). This form must be taken by the employee to the doctor visit. A new form must be filled out by the supervisor every time the employee sees a doctor. After a doctor fills out the form, it must be returned to the supervisor. The supervisor will scan and email the form to the Environmental Health and Safety Office - ehs@mst.edu.
Authorized Providers / Facilities
Only the following facilities are authorized by Missouri S&T to provide treatment:Phelps Health Immediate Care Rolla (603 S. Bishop Ave.)
Unit C
(573) 426-4411
Monday thru Friday 8:00 AM to 8:00 PM, Saturday and Sunday 8:00 AM to 6:00 PMRolla Family Clinic LLC (1060 South Bishop)
573-426-5900
Monday thru Friday 9:00 AM to 9:00 PM, Closed 1:30PM to 2:00PM for lunchMercy Clinic & Dr. After Hours (Located at Mercy Clinic, 1605 Martin Springs Drive)
Suite 230
(573) 458-6350
Monday thru Friday 7:30 AM to 7:00 PM, Saturday, Sunday, and Holidays 8:00 AM to 4:00 PM.Emergency of after hours care
Phelps County Regional Medical Center Emergency Room (1000 West 10th Street)
State Law allows the employer to choose where their employees will be treated when they are injured on the job. In order to take advantage of the benefits for medical treatment, Missouri S&T employees MUST use the authorized facilities designated for their campus/area with the following exceptions. If an employee is in a location outside their normal work area, they may utilize the closest medical facility. In addition, if an employee requires treatment for a life-threatening condition; they may go to, or be transported to, the nearest medical facility.
NOTE: Do not confuse workers compensation with your personal health insurance as they are different programs. If an employee seeks treatment for a work related injury with an unauthorized physician, including chiropractic treatment, the employee will be responsible for the bills. - For ALL Injuries the Supervisor MUST
Fill out a Report of Injury (UM WC-1) Rolla
The Report of Injury Form is the claim form that should be completed by the supervisor.
This Report of Injury Form must be typed, scanned, and emailed within 24 hours to the Environmental Health & Safety Office - ehs@mst.edu and Human Resources - msthrsupport@mst.edu.
Fill out an Accident Investigation Form
This form is to be completed by the appropriate supervisor for all workplace accidents and/or near misses. Unsafe acts of employees and unsafe conditions that cause accidents can be corrected only when they are specifically known. It is the supervisor’s responsibility to find them, identify them and to state the remedy in this report.
The supervisor is to forward the completed form to Missouri S&T’s Environmental Health and Safety (EHS) Department within 48 hours of the injury. EHS will review the accident investigation and when necessary, discuss the information provided with Department Chairs/Directors.
Missouri S&T’s EHS Department will provide oversight and track completion of the reports and preventative actions taken by the department. Incomplete reports will be returned to the supervisor for further information.
Missouri S&T’s EHS Department will maintain information for reports summarizing preventative actions completed and actions pending completion.
- Links to HR Policy Manual
HR 307 Workers Compensation
HR 409 Work-Incurred Injury or Illness
2. Workers' Compensation - Modified Duty
The Modified Duty Program is for injured employees who have filed a Workers’ Compensation claim and have been released to return to work by the treating physician. The following procedure must be followed when an employee incurs a work related injury.
1. When an employee is injured on the job and the injury is non-emergency in nature, the department completes the Report of Injury (UM WC-1) Rolla and a Workers Compensation Physician Referral (Missouri S&T 245) and refers the injured employee to Doctor After Hours (walk-in), Mercy Clinic, or the Emergency Room (after hours and weekends) for assessment, diagnosis and a treatment plan. The department manager then notifies Environmental Health and Safety (EHS) of the injury and forwards the completed Report of Injury Questionnaire. The injured employee will return the Form Missouri S&T-245 to the department manager who will then scan and email it to EHS. EHS will consult with the Workers’ Compensation Administrator for case management.
For emergency injures the employee should report to the Emergency Room at Phelps Health. The department manager completes the Report of Injury (UM WC-1) Rolla and Workers Compensation Physician Referral (Missouri S&T 245) and notifies EHS who will consult with the Workers’ Compensation Administrator.
2. An employee returning to work after a work related injury must provide the department manager with a written release from a physician. The release must indicate the scope of injury/illness and clearly state the employee’s ability to return to work with the defined restrictions. The release should also indicate the approximate length of time the restrictions are expected to last and the prognosis for a full recovery. The department manager reviews the request for Modified Duty from the physician with Human Resources and EHS and must provide a Modified Duty assignment within their department or in another department. If a department does not bring back the employee for Modified Duty, the department will reimburse the University’s Workers’ Compensation Fund $500 per week to commence the first day the employee is not returned to work. A partial week will be considered as a full week. EHS or the medical provider will notify the Workers’ Compensation Adjustor of the Modified Duty.
3. Information regarding the essential duties, periodic duties, and physical requirements of the job are crucial in determining Modified Duty assignments. To provide meaningful Modified Duty assignments, some job duties and assignments may be outside the employee’s normal job duties and department. When employees are assigned modified duties outside their normal job duties and/or department, the department manager in that area will determine the amount of training and orientation needed for the job.
4. After the Modified Duty assignment is reviewed by Human Resources, EHS and the department manager; and is approved, the employee will then review and sign the Modified Duty Statement (Missouri S&T 246). Upon signing the Form 246, the employee acknowledges the assignment is temporary and will stop after 90 days whether or not the employee is able to resume full duties. The department will send copies of the signed form to Human Resources and EHS.
5. The employee who is brought back to Modified Duty (75% FTE or 30 hours per week) will be paid for hours worked at one half the employee’s regular hourly rate. In addition, Workers’ Compensation will pay two-thirds of the difference between the employee’s average weekly wage and the pay for hours worked at the one half rate. The employee would then be allowed to use sick leave to supplement pay to equal the full paycheck of 40 hours per week at the full rate of pay. For example:
Regular Pay (REG) = 40.0 hours at $16.00/hour = $640.00/week
Modified Duty Rate (MDR) = 30.0 hours at $8.00/hour = $240.00/week
Difference = $400.00
Workers’ Compensation pays 2/3 times the Difference = $266.68
Regular Full Paycheck $640.00
Modified Duty Pay - $240.00
Workers’ Comp. Pay - $266.68
Sick Leave Charged to Supplement Check = $133.32
Amount to pay in sick leave divided by employee’s regular hourly rate = number of hours to charge to sick leave. $133.32/16.00 = 8.33 hours Sick Leave
Department to pay @ MDR rate $240.00 (30.0 hours worked at $8.00)
Department to pay @ REG rate $133.32 (8.33 hours sick leave at $16.00)
Total paid by University payroll $373.32
Total paid by Workers’ Comp. self-insured fund $266.68
Total amount paid $640.00
6. The employee’s medical status will be reviewed within 60 days after beginning the Modified Duty Program. The physician will provide written review of the medical status and include a possible prognosis for full recovery. If the employee’s condition is not improving, the employee may be placed on a Leave of Absence (LOA) status. If the employee is improving the Modified Duty assignment may continue.
7. After 90 days, if the employee is not able to return to full duty, the employee will be placed on a Leave of Absence (LOA) status until provided a full work release by the physician. If the employee is able to return to work, the employee must obtain a written release from the physician stating the employee is recovered and ready to return to the full duties of the employee’s work.
8. If the employee is on a concurrent Family Medical Leave Act (FMLA) leave, the employee may choose not to accept the Modified Duty assignment. The employee would remain on FMLA status but only be entitled to the Workers’ Compensation portion of the difference between modified duty pay and total compensation.
EFFECTIVE DATE: November 21, 2000
Revision Date: January 7, 2009
June 8, 2009
Definitions:
Vehicle Accident - Vehicles involved in an accident, any University-owned vehicle, any employee-owned vehicle used on official University business and any vehicle rented or leased by or for the University.
Vehicle Accident Report (UM-5)
This form has two tabs, please be sure to complete both page 1 and page 2. Email a scanned copy of the completed report to the Environmental Health and Safety Office - ehs@mst.edu.
*This document shows 10 wallet size cards for distribution to personnel in your department. It is recommended to duplex (double side) print this document.
Auto Liability – What to do when you are in an accident while on official University business
Reporting process for vehicle accidents involving any University-owned vehicle and any vehicle rented or leased by or for the University.
All Auto Liability Claims must be filed with the Environmental Health and Safety Office within 48 hours of the accident, within 24 hours if there is a fatality.
University Owned Vehicle:
- Immediately following the accident, contact the local police or the State Highway Patrol if available, if not, contact the nearest police station or judicial officer.
- Missouri law requires that drivers involved in an accident causing bodily injury or property damage must stop and exchange the following information to the other driver(s) or the injured party: name, address, license number and chauffeur’s or operator’s license number.
- While at the scene of the accident or as soon as possible complete the Vehicle Accident Report, UM-5 (above). The VIN number, license plate number and MoCode must be on the report.
- Send the completed Vehicle Accident Report to your Department Chair or Supervisor, who should report to the campus claims coordinator within 24 hours if bodily injury or 48 hours if no bodily injury. The report must be signed by a supervisor. E-mail a scanned copy of the complete report to the Environmental Health and Safety Office - ehs@mst.edu.
- Remember, do not discuss the accident with anyone except representatives of the university, its insurance company and law enforcement officers, and do not make any admission as to who was at fault nor attempt to settle claims or otherwise establish liability with the other parties of the accident or their insurance companies.
Rented Vehicle Used on Official University Business:
1. Immediately following the accident, contact to the local police or the State Highway Patrol if available, if not, contact the nearest police station or judicial officer.
2. Missouri law requires that drivers involved in an accident causing bodily injury or property damage must stop and exchange the following information to the other driver(s) or the injured party: name, address, license number and chauffeur’s or operator’s license number.
3. While at the scene of the accident or as soon as possible complete the Vehicle Accident Report, UM-5 (above). The VIN number, license plate number and MoCode must be on the report. Note in the accident information if the vehicle was secured with a MasterCard or if the department accepted the rental companies insurance. The report must be signed by a supervisor.
4. If your vehicle was rented using a University issued purchasing card call 1-800-MCASSIST (1-800-622-7747) to report your accident to the MasterCard insurance. The card holder must be the individual to call MasterCard. Have the following documents available:
- Receipt from rental
- Copy of the rental agreement
- Police report/accident report if available
5. Email scanned copies of all correspondence with the rental company and MasterCard to Environmental Health and Safety - ehs@mst.edu.
6. Send the completed Vehicle Accident Report to your Department Chairman or Supervisor, who should report to the campus claims coordinator within 24 hours if bodily injury or 48 hours if no bodily injury. The report must be signed by a supervisor. E-mail a scanned copy of the complete report to ehs@mst.edu.
7. Remember, do not discuss the accident with anyone except representatives of the university, its insurance company and law enforcement officers, and do not make any admission as to who was at fault nor attempt to settle claims or otherwise establish liability with the other parties of the accident or their insurance companies.
With any questions regarding vehicle accidents please contact Environmental Health and Safety at 573-341-4305 or ehs@mst.edu. Please contact EHS if you would like a wallet sized copy of an auto claim checklist.
For more specific information about coverage go to http://www.umsystem.edu/ums/fa/management/risk/insurancecoverages-automobile#overview
4. All Workers Compensation & Risk Insurance Forms
Workers' Compensation - Forms
- Report of Injury (UM WC-1) Rolla
- Accident Investigation Form
-
This form is to be completed by the appropriate supervisor for all workplace accidents and/or near misses. Unsafe acts of employees and unsafe conditions that cause accidents can be corrected only when they are specifically known. It is the supervisor’s responsibility to find them, identify them and to state the remedy in this report.
The supervisor is to forward the completed form to Missouri S&T’s Environmental Health and Safety (EHS) Department within 48 hours of the injury. EHS will review the accident investigation and when necessary, discuss the information provided with Department Chairs/Directors.
Missouri S&T’s EHS Department will provide oversight and track completion of the reports and preventative actions taken by the department. Incomplete reports will be returned to the supervisor for further information.
Missouri S&T’s EHS Department will maintain information for reports summarizing preventative actions completed and actions pending completion.
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- Workers Compensation Physician Referral (Missouri S&T 245)
- Workers Compensation Therapist Referral (Missouri S&T 245A)
- Modified Duty Statement (Missouri S&T 246)
- Mileage Reimbursement
The risk insurance forms have been converted to an Excel format to simplify the process. The Excel option allows each user to fill out the form electronically; therefore ALL forms below must be completed electronically. Once the form is completed electronically the user can save and email it to ehs@mst.edu within 24 hours after the accident or incident occurred.
Some forms have two tabs, please be sure to complete both page 1 and page 2.
- Vehicle Accident Report (UM-5)
- Vehicles involved in an accident, any University owned vehicle, any employee owned vehicle used on official University business, and any vehicle rented or leased by or for the University.
- Auto Liability Checklist
- Damage Report (UM-69)
- All damage to or destruction of any University owned or leased building or facility or its equipment, machinery, furniture and fixtures.
- Disappearance of Assets and Money (UM-155)
- The theft or disappearance of money, securities, property or equipment owned by the University, rented or leased by or for the University, or which the University has legally accepted custody and responsibility.
- Student or General Public Injury and Property Damage Report (UM-200)
- Accidents and incidents resulting in injury to students (not in employment status) or general public and/or their property.
6. Frequently Asked Questions (FAQ)
1. Where do we send employees when they are injured, for initial treatment?
Phelps Health Medical Group (1050 W. 10th Street)
Suite 300
Phone (573) 458-3899, Please call if possible before you visit.
Monday thru Friday 8:00 AM to 4:30 PM
Phelps Health Immediate Care Rolla (603 S. Bishop Ave.)
Unit C
(573) 426-4411
Monday thru Friday 8:00 AM to 8:00 PM, Saturday and Sunday 8:00 AM to 6:00 PM
Mercy Clinic & Dr. After Hours (Located at Mercy Clinic, 1605 Martin Springs Drive)
573-458-6350
Suite 230
7:30AM to 7:00PM Monday - Friday, 8:00AM to 4:00PM Saturday, Sunday, and Holidays
Rolla Family Clinic LLC (1060 South Bishop)
573-426-5900
9:00AM to 9:00PM Monday - Friday, Closed 1:30PM to 2:00PM for lunch
Emergency of after hours care
Phelps County Regional Medical Center Emergency Room (1000 West 10th Street)
2. Where do we send employees for physical therapy?
We use Mercy Clinic and Phelps County Regional Medical Center. These appointments must be pre-approved and scheduled by the University Department, workers' compensation, Adjusters.
3. Can you clarify the 3-day waiting period rule that went into effect August of 1998 and the two new rules set by the Division of Workers’ Compensation that were effective March 1, 1999?
Three Day Waiting Period
The state of Missouri has us look at what days the employer is open to conduct business in regards to lost time and the waiting period in general. If the employer is open seven days a week (which the University is) then we do consider days that the employee may not normally be scheduled into the waiting period.
Example: John Doe works Monday through Friday. He is injured on a Wednesday. He is taken off work by the treating physician on Thursday. His waiting period would be Thursday, Friday, Saturday. His 1st day of lost time would be Sunday.
The state will allow us to reimburse the waiting period once the employee has reached his 15th day of disability.
4. Submitting Reports of Injury
All reports of injury being submitted must reach the University third party administrator within 5 days of the illness or injury or within 5 days of the University’s receiving notice from the employee of the illness or injury. They, in turn, must file all reports with the Division within 10 days of receipt from the University.
5. Illnesses or Injuries Resulting in Lost Time Without Incurred Medical Cost
A Report of Injury must be submitted to the Environmental Health and Safety department, for any work related illness or injury for which an employee is formally excused from work by a medical professional whether or not a cost is incurred. It does not include illnesses or injuries of employees who are absent without a formal excuse from work by a medical professional, nor does it include excused absences for the reminder of the day of illness or injury.
NOTE: This is a departure from the past practice of submitting Reports of Injury only in those instances where an employee was seen by a physician and a charge was incurred for the visit.
6. Does an Accident Investigation Report need to be filled out for each Report of Injury?
Yes, an accident investigation report needs to be filled out for each injury whether the employee sought medical attention or not.