Florida Workers Comp - Resource Page

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WORKERS COMPENSATION RESOURCE PAGE

HIRING:

It is CRITICAL for you and your team to hire only the best people and to invest the proper time upfront in screening appl icants. Consider having employees review and sign the fol lowing forms:

Post-Hire Accommodation form helps ensure employees are placed in a safe job for them. http://www.ProfitingFromSafety.com/downloads/AccommodationFormSample.doc Employee Agreement ensures employees agree to work safely. http://www.ProfitingFromSafety.com/downloads/EmployeeSafeWorkAgreement.doc Safe Driving Acknowledgement ensures employees agree to drive safely i f they have to drive for your business. http://www.ProfitingFromSafety.com/safe-driving-pol icy/ Robbery Training Acknowledgement ensures employees agree to ensure the highest level of safety i f a robbery occurs. http://www.ProfitingFromSafety.com/robbery-pol icy/

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Disclaimer This information is offered as an informational resource to Owner/Operators (O/O). O/Os are exclusively responsible for complying with all statutes, laws, and regulations applicable to their restaurant(s). For any legal issues affecting their business, O/Os should consult their own legal counsel. This communication is informational only and should not be construed as legal advice or as establishing requirements applicable to any O/O. O/Os are independent employers and make their own policies regarding employment-related matters, including policies and practices relating to providing orientation to their employees. O/Os may choose to use these materials to the extent that they will be helpful to them in operating their own restaurant(s). If you work for an O/O, please check with your O/Os, or the person designated by your O/O, to determine whether these materials apply to your restaurant.

http://www.profitingfromsafety.com/disclaimer/

ACCOMMODATION REQUEST FORM

A. Questions to clarify accommodation requested. What specific accommodation are you requesting?

If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?

Yes 

No 

If yes , please explain. Is your accommodation request time sensitive?

Yes 

No 

If yes , please explain. B. Questions to document the reason for accommodation request. What, if any, job function are you having difficulty performing?

What, if any, employment benefit are you having difficulty accessing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Yes 

No 

Have you had any accommodations in the past for this same limitation?

If yes , what were they and how effective were they? If you are requesting a specific accommodation, how will that accommodation assist you?

C. Other. Please provide any additional information that might be useful in processing your accommodation request:

______________________________

_______________

Signature

Date

Return this form to ______________________

Please read the following important disclaimer information concerning the information found on this page: http://www.besnardinsurance.com/profitingfromsafety/disclaimer/ All Rights Reserved © Besnard Insurance

EMPLOYEE AGREEMENT EMPLOYEE SAFE WORKING PRACTICES

As a condition of employment, I _____________________________ do hereby agree to comply with the following Employee Safe Working Practices.

1. I agree to follow established departmental safety procedures. 2. I agree to report any work-related accident or injury to my supervisor as soon as it occurs, but no later than the end of my duty shift. 3. If I need treatment for a work-related injury, I understand that: a. I must first report any work-related injuries to my supervisor as soon as it occurs. b. In a medical emergency I may be transported to the nearest medical facility, or 911 may be called for emergency assistance; and c. The medical provider used must be authorized by my employer or the insurance company, and they will provide and/or coordinate the necessary medical care, treatment and prescriptions related to my injury

I understand that failure on my part to follow the above procedures could result in disciplinary action not to exclude termination and loss of Worker’s Compensation benefits.

I also understand that the State in which I work may have laws which reduce my compensation benefits for injury that occurs because of failure to follow established safety procedures.

____________________________

_____________________

Employee Signature

Date

____________________________

_____________________

Witness Signature

Date

Original to Personnel File/ Copy to Employee

Safe Driving Training Acknowledgement Form

Auto accidents are a problem that we have the potential of facing when driving for work related business. In order to keep our employee’s safe; we have the following policies to help reduce any harm to yourself and others.

Safe Driving Policy:

• I agree my vehicle will be properly maintained

• I agree to not drink alcohol, or illegal drugs, in any quantity, prior to driving, or while driving.

• I agree not to take any prescription drugs that may impair my ability to safely drive.

• I agree to wear my seatbelt at all times, when I am driving.

• I agree to not give rides to any passengers while driving.

• I will report any driving violations at first opportunity.

• I will ensure that my vehicle is properly insured, with insurance being kept up to date.

• I agree to report any accidents whether during personal driving time or during company business to my manager immediately. I will not admit fault, and I will get witness names, and contact information.

• I agree to follow all State and local laws and rules while driving

• I agree to never Text Message while in the car. Even if stopped at a light, I will not check text messages or send them

• I will never check (or send) Emails while in the car

• When driving, I will use caution and drive responsible at all times

• When driving, I will continuously look out for pedestrians

• When driving, I will not drive aggressive and will leave plenty of stopping distance in front of my vehicle

• When driving, I will not make any moves that may endanger anyone's safety.

*** I understand when driving on restaurant business that all lives and property are more important than being on time.

Employee Name: ______________________________

Employee’s Signature: ______________________________ Date: ____________

Managers/Witness Signature: ______________________________ Date: ____________

SAMPLE Document (Revise to match your company policies and keep a signed copy in employee file) Robbery/Security Policy Acknowledgement At [XYZ], employee’s safety is top priority. It is important for all employees to view the safety/security e learning video and to know how to react in the event of an emergency. After watching the safety/security video, please review the policies below to ensure that you fully understand all policies that will increase the safety level. I agree to the following company safety/security procedures: After Dark Policies: Applicable in all restaurants  I understand that all lobby doors must remain locked and closed in the event that there are less than 3 employees in the store (Excluding Wal-Mart locations). If this policy is broken by your shift manager please notify your store manager or supervisor.  I understand that the back door may not be open after dark to remove trash. Trash cannot be taken out after dark. I will notify the manager on duty if I see people loitering or pan handling in the parking lot or lobby  24 hour DT only restaurants: I understand that I am not permitted to take a smoke break once the lobby doors are locked for the evening.  All 24 hour restaurants: I understand that at least 4 employees have to be wearing a Drive-Thru headset at all times to increase communication in the event of an emergency. Robberies are a problem that we have the potential of facing. All lives are far more important than whatever money may be in a cash register or safe at any time. As a result, I agree to follow our company procedures in the event of a robbery: During a robbery:  I will remain calm and do exactly as told.  I will not hesitate or argue. In most cases, the robber does not wish to harm anyone, but just wants the money. I will not try and “be a hero”. I will give the robber whatever money they want. *** I understand that all lives are more important than any amount of money. The above policies are put in place to ensure the highest level of safety. Signing your name below, shows that you have read and agree to follow all safety and security policies listed above. Employee Name: ______________________________ Employee’s Signature: ______________________________ Date: ____________ Managers/Witness Signature: ______________________________ Date: ____________  I will give the robber(s) whatever money they want immediately.  I will not make any moves that may endanger anyone's safety.

TRAINING:

Safe practices should be taught and enforced starting with their f irst shi ft. The Safety Checkl ist found below is a great tool to help ensure training is performed consistently.

http://www.ProfitingFromSafety.com/downloads/OrientationCheckl ist.doc

SAFETY AWARENESS & MEETINGS:

Promoting safety awareness among al l workers is critical in establ ishing and maintaining a safe work environment. Posting safety bul letins on relevant safety issues is a good way to promote safety awareness. Safety bul letins, short training videos, and other training materials may be accessed, free of charge, from www.profitingfromsafety.com. Free safety posters can be downloaded here: http://www.ProfitingFromSafety.com/posters/ Safety Meetings is another way to maintain high safety awareness. Schedule safety discussions as part of each management and crew meeting. Below is a l ink to learn more about holding effective safety meetings.

https://www.profitingfromsafety.com/making-safety-meetings-work/ http://www.ProfitingFromSafety.com/downloads/SafetyTeamMinutes.doc

Restaurant Safety Review - Visual ly inspect your restaurant during your pre-shi ft preparation. Each travel path should be inspected. When necessary, take immediate steps to f ix problems and prevent accidents and injuries. Below is a sample inspection form. http://www.profitingfromsafety.com/downloads/SelfSafetyReview.pdf

NEED HELP? Email us at: Support@msusafetytraining.com

Safety Orientation Checklist It is required that the supervisor thoroughly instructs each new employee in the safety requirements of the job and this checklist is provided for the accomplishment of that purpose. Directions : Check each of the items on this form at the time instruction is given and when completed. Please sign it and return it to the Personnel Department for placement in the employee’s file. Employee’s Name:________________________________________________ Occupation: ____________________________________ Date Hired:___________ Topics Discussed Completed 1. Shoe Policy - “no shoes, no work” 2. Safe Lifting Procedures – Demonstrate lifting with legs, etc. 3. Review Hazards (All known potentially dangers) 4. Burn Prevention and Protective Devices 5. Proper Stacking of Items 6. Proper Floor Safety and Care 7. Review Chemical Safety and Safety Data Sheets 8. Robbery Procedures 9. Safety Products - Location and Use of 10.Emergency Procedures 11.Security Review and Procedures 12.Report Any Injury Immediately (even if minor) 17.Personal Hygiene and Hand Washing 18.Safety Vest – Location and Usage 19.Demonstration and Follow Up I have instructed the above new employee in the safety requirements checklist and feel he/she can be expected to perform his/her duties safely. Manager: ________________________________________________________ Employee Name: ______________________________ Hire Date: ____________ Signed by Employee: _________________________ Date Reviewed: ____________ 13.Return to Work Policy 14.Proper Housekeeping 15.Fire Prevention 16.Driving Policy

Safety Inspections – Self Review

Visually inspect your restaurant during your pre-shift preparation. Each travel path should be inspected. When necessary, take immediate steps to fix problems and prevent accidents and injuries. If a safety issue is identified but cannot be immediately corrected (such as a pothole in the parking lot), a specific action to correct the problem should be scheduled, and others should be warned of the condition.

Examples of common unsafe Work Practices include:

 Failure to clean floors according to schedule and proper procedure  Failing to use proper personal protective equipment  Using improper lifting procedures  Improper or inappropriate conduct  Disregarding company safety rules  Improper procedures when working near hot surfaces  Standing on furniture or chairs  Failure to create a safe culture  Leaving freezer door open to o long during loading

Common unsafe Conditions include:

 Water, ice, or oil on walking surfaces  Congested aisles  Faulty electrical equipment  Poor housekeeping  Top-heavy stacks of cartons

 Defective equipment  Ice build-up in freezer

DAILY STORE SAFETY INSPECTION CHECKLIST (Worker Injury Prevention)

National Store Number: ___________Location: ________________________________________________

Inspector Name: ___________________________________________Date: __________________________

Directions: Please indicate with a √ under the “Y” or “N” column for each item inspected and “N/A” if the item is not applicable. Please place a √ under

“corrective actions” column if corrective actions are needed or if they have already been implemented immediately. Please complete the “Corrective

Actions Follow- Up” section on the last page of this inspection report for all action items containing a √ under the “corrective actions” col umn. Once all

corrective actions have been completed, this report should be maintained in a master file for future analysis. FLOORS & WALKING SURFACES Y N

N/A Corrective Actions

Are floors around the fryer free of grease? Are all floor mats and carpets in place and clean?

Are ALL employees wearing approved slip-resistant footwear? Are primary walkways clear of obstructions such as boxes, bun racks, materials, or other tripping hazards? Are the floor surfaces in the main dining areas in good condition? Was deck brushing completed on all floors today? STORAGE Y Are lighter materials such as cups & paper products stored on the top shelves? Are heavier, frequently used items stored on the middle shelves? Are the floor surfaces in the walk-in freezers in good condition? (no ice buildup at entrance of walk-in freezers) Are lights working properly inside walk-in cooler or freezer? Are soda syrup box racks in an easily accessible area on waist height shelves? EQUIPMENT/APPLIANCE SAFETY Y Is there adequate personal protective equipment (PPE) available to those employees changing the grease from the fryers? (gloves, etc.) Are cleaning mops, deck brushes and squeegees clean and ready for use? Are face-shields and safety goggles hung and available? CHEMICAL SAFETY Y Are all cleaning chemicals properly stored? Is personal protective equipment available to employees when using cleaning chemicals? (gloves, goggles, etc.) Are compressed gas cylinders properly secured with a chain? TRASH, EXTERIOR, and OTHER ITEMS Is the trash area secured?

N/A Corrective Actions

Is the ladder locked?

Are all cameras working properly and lenses clean?

Is all the outside lighting working properly?

Is the outside parking lot clean? OTHER RELEVANT SAFETY CONSIDERATIONS

N/A Corrective Actions

RESTAURANT – CO R RECTIVE ACTIONS (Worker Injury Prevention)

It is recommended that you contact your workers compensation insurance company’s loss consultant to help you with corrective actions.

Corrective Action Needed

Person Responsible

Date Completed

CLAIMS MANAGEMENT:

Properly managing your claims can improve your claims outcome and save you money. Uti l ize the claim management check- l ist to ensure everything is completed for al l claims.

http://www.besnardinsurance.com/resources/MCD/MCD_WC_ClaimsCheckl ist.pdf

If a worker has an incident and refuses medical treatment have them complete the form below.

http://www.ProfitingFromSafety.com/downloads/MCD_EMPLOYEE_WAIVER.pdf

Make sure you gather al l the information needed when a worker is injured. Using the l ink below, download a template to ensure you record the proper information. https: //myf loridacfo.com/docs-sf/workers-compensation-l ibraries/workers comp-documents/forms/69l-3/dfs-f2-dwc-1-(interactive).pdf? sfvrsn=8558a802_4

Addi t ional MyFlor idaCFO l inks you may f ind helpful .

https://myfloridacfo.com/division/wc/forms

Please use the form below to gather additional written statements about the accident from the claimant and any additional witnesses.

http://www.ProfitingFromSafety.com/downloads/MCD_ADDITIONAL_STATEMENTS.doc

Managers should perform accident investigations to determine the cause of al l injuries. Below is a template to assist them with their investigations.

http://www.ProfitingFromSafety.com/form-accident- investigation/

NEED HELP? Email us at: Support@msusafetytraining.com

CLAIM MANAGEMENT CHECK-LIST (Workers Compensation) (Please attach this document to the outside of internal claim folder)

Workers Name: ____________________ Date of Accident: ______ Store #: _____

STORE MANAGER Initiate choice of medical provider set by your state (if applicable)

Send the injured worker for a post-accident drug screen (if applicable in your HR policy) If the injured worker declines care, have them sign the waiver of medical treatment form Complete and perform an Accident Investigation (complete the form) Report Claim – immediately (always within 24 hours) o Everything sent to the Insurance Company (or your Main Office) o Gather and review video as soon as possible o Contact claims adjuster or main office to let them know what can be seen o Save at least 30 minutes of video before and after from all cameras in store Return to Work o Follow-up with the worker to schedule their return shift Return to Work (Leadership Communication) o Contact your leadership if it is not going to be possible to return them in __ DAYS from the accident date or if they do not follow up with you o Call your claims adjuster with an update Follow-up with Store Manager o Ensured worker returned by the specified time/date  Request that the injured worker return to you with a work status and doctors note  You only have a __ DAY WAITING PERIOD (waiting period varies by state). It is important to get the injured worker back to work within that time period. Ensure video is saved

CLAIMS MANAGER

EMPLOYEE WAIVER OF MEDICAL TREATMENT

DATE: EMPLOYEE NAME:

As of the date noted above, I am notifying my employer of an injury that occurred on

, 201  My supervisor did not receive notification of thisincident.  My supervisor did receive notification of this incident on

, 201

This injury, (briefly describe condition)

occurred during the normal scope and duties of employment. My employer has offered me medical treatment for the above noted condition . I decline to be medically evaluated for the above noted condition. I understand that by signing this document, any future claims regarding this injury will require a medical evaluation through my employer’s workers compensation or I may be responsible for any medical bills or lost wages. I also understand that should I seek treatment for this injury, I must first notify my supervisor.

SHOULD THE CONDITION BECOME LIFE THREATENING SEEK APPROPRIATE EMERGENCY CARE IMMEDIATELY

EMPLOYEE STATEMENTS

By signing this form, I acknowledge: • I have not sought medical treatment for this injury

• I have read the above information and agree it is factual and true statement. I authorize any physician, hospital or healthcare provider to release and furnish any and all medical records or other information pertaining to the above listedcondition.

Employee Signature

Supervisor/Witness Signature

Date

RECEIVED BY CLAIMS-HANDLING ENTITY

FIRST REPORT OF INJURY OR ILLNESS

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

PLEASE PRINT OR TYPE NAME (First, Middle, Last)

EMPLOYEE INFORMATION

Social Security Number

Date of Accident (Month-Day-Year)

Time of Accident

HOME ADDRESS

EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

Street/Apt #: _________________________________________________________

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

OCCUPATION

INJURY/ILLNESS THAT OCCURRED

PART OF BODY AFFECTED

DATE OF BIRTH

SEX

_________ / _________ / _________

EMPLOYER INFORMATION

FEDERAL I.D. NUMBER (FEIN)

DATE FIRST REPORTED (Month/Day/Year)

COMPANY NAME: ___________________________________________________

D. B. A.: ____________________________________________________________

NATURE OF BUSINESS

POLICY/MEMBER NUMBER

Street: _____________________________________________________________

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

DATE EMPLOYED

PAID FOR DATE OF INJURY

_________ / _________ / _________

YES

LAST DATE EMPLOYEE WORKED

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS' COMP? YES

EMPLOYER'S LOCATION ADDRESS (If different)

_________ / _________ / _________

Street: _____________________________________________________________

LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS' COMP

RETURNED TO WORK IF YES, GIVE DATE

YES

City: ________________________ State: _______________ Zip: ______________

_________ / _________ / _________

LOCATION # (If applicable) ____________________________________________

_________ / _________ / _________

DATE OF DEATH (If applicable)

RATE OF PAY

PLACE OF ACCIDENT (Street, City, State, Zip)

_________ / _________ / _________

$ _________________ PER

DAY

Street: _____________________________________________________________

AGREE WITH DESCRIPTION OF ACCIDENT?

Number of hours per day

City: _________________________ State: _______________ Zip: ______________

______________________

YES

Number of hours per week

______________________

COUNTY OF ACCIDENT ______________________________________________

Number of days per week

______________________

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I have reviewed, understand and acknowledge the above statement.

NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL

__________________________________________________________________

_______________________________________________

EMPLOYEE SIGNATURE (If available to sign)

DATE

__________________________________________________________________

_______________________________________________

EMPLOYER SIGNATURE

DATE

AUTHORIZED BY EMPLOYER

YES

CLAIMS-HANDLING ENTITY INFORMATION

1(a) Denied Case - DWC-12, Notice of Denial Attached

2. Medical Only which became Lost Time Case (Complete all required information in #3)

Employee’s 8 TH Day of Disability

1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached

_________ / _________ / _________

Entity’s Knowledge of 8 TH Day of Disability _________ /_________ / _________

3. Lost Time Case - 1st day of disability _________ / _________ / _________

Full Salary in lieu of comp? YES Full Salary End Date ________/ ________ / ________

Date First Payment Mailed _________ / _________ / _________

AWW ____________________________

Comp Rate ____________________________

T.T.

T.T. - 80%

T.P.

I.B.

P.T.

DEATH

SETTLEMENT ONLY

Penalty Amount Paid in 1 st Payment $___________

Interest Amount Paid in 1 st Payment $__________

REMARKS:

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

EMPLOYER'S NAICS CODE

EMPLOYEE'S CLASS CODE

INSURER CODE #

SERVICE CO/TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 ( 10 /20 16 ) Rule 69L-3.025, F.A.C.

Accident Additional Statements Please use this form to gather additional written statements from the claimant about the accident as well as any additional witnesses

CLAIMANT STATEMENT (Please explain in detail how the accident occurred? What are your complaints/injuries?) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Name: __________________________

Signature____________________ Date__________

I confirmed this information is accurate and true.

WITNESS STATEMENT (What did you see, what do you remember? Were there any additional witnesses? What did the injured worker tell you?) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Name: __________________________

Signature____________________ Date__________

I confirmed this information is accurate and true.

MANAGER’S ACCIDENT INVESTIGATION FORM

DATE

TIME

AM PM

AGE

EMPLOYEE INVOLVED

NOTE TO SUPERVISOR: Remember, an accident investigation is not designed to find fault or blame. It is an analysis to determine cause that can be controlled or eliminated. When completing the investigation, try to answer these questions.  How did the accident occur?  Where did it happen?  What station did this occur?  Who was injured?  When did it happen? RECOMMEND CHANGES: No investigation is complete unless corrective action is suggested. FOLLOW-UP: Determine what action is being taken on your recommended changes.

DATE EMPLOYED

POSITION

MANAGER ON DUTY

HAS THIS INCIDENT BEEN REFERRED TO THE SAFETY COMMITTEE? YES NO WAS THE TASK: ROUTINE INFREQUENT NEW EXPERIENCE WERE THERE WITNESSES? IF SO, ATTACH STATEMENT

HOW LONG HAS THE EMPLOYEE BEEN DOING THIS TASK?

HAS THE EMPLOYEE HAD THE PROPER TRAINING?

DID THE ACCIDENT RESULT IN INJURY? HAVE SECURITY RECORDINGS BEEN RETAINED?

NATURE AND EXTENT OF INJURY?

DATE INJURY REPORTED?

WAS FIRST AID GIVEN?

HOW DID THE ACCIDENT OCCUR?

PRIMARY CAUSE OF ACCIDENT?

RECOMMENDATIONS TO PREVENT RECURRENCE

NAME OF PERSON RESPONSIBLE FOR CORRECTIVE ACTION

WHAT ACTION HAS BEEN TAKEN?

DATE

SIGNED

RETURN-TO-WORK POLICY:

Having a written return to work pol icy wi l l ensure al l employees understand what to expect i f they are injured on the job. Below is a sample pol icy. http://www.ProfitingFromSafety.com/rtw-a-win-for-al l/ If an injured worker seeks medical treatment from a doctor, they should request a work status letter from the provider so you understand i f they have any l imitations fol lowing an injury. Below is a sample return to work letter you can use when offering transitional duty work. http://www.ProfitingFromSafety.com/downloads/ReturntoWorkLetter.doc Transitional duty work wi l l get employees back to work faster.

http://www.profitingfromsafety.com/wp-content/uploads/2015/07/Return-To-Work.pdf

ADDITIONAL RESOURCES

ONLINE SAFETY UNIVERSITY: www.ManagerSafetyU.com SAFETY RESOURCES (AND NEWSLETTER): www.Prof itingFromSafety.com OTHER HELPFUL SITES: Workers Compensation 101 – Learn the Basics http://www.besnardinsurance.com/workers-compensation-2/faqs/ Hiring Support http://www.ProfitingFromSafety.com/category/automobi le/ https://www.travelers.com/resources/driver-fleet-safety/safe-drivers-for-your-business https://www.osha.gov/Publ ications/motor_vehicle_guide.html Property and General Liabi l ity http://www.ProfitingFromSafety.com/category/propertyl iab/ Employment Practices Liabi l ity http://www.ProfitingFromSafety.com/category/employment-practices/ Credit Card Liabi l ity http://www.ProfitingFromSafety.com/category/credit-card/ Safety Products http://www.ProfitingFromSafety.com/category/safety-products/ http://www.ProfitingFromSafety.com/category/hiring/ https://www.profitingfromsafety.com/profit-sheet-hiring/ Automobi le Safety

RETURN-TO-WORK POLICY (Sample) Please read the following carefully. This policy applies to all employees with work related injuries.  Our Company is committed to maintaining the safety, health and productivity of our employees.  Modified and transitional duty is a temporary work offer pending determination of an employee’s ability to return to regular duty work.  It is this company’s policy that injured employees accept and fully cooperate with modified and transitional duty work found suitable by the attending physician.  Failure to accept modified or transitional duty work that the attending physician has found to be within the employee’s capabilities may result in the reduction or suspension of time loss benefits.  Failure to comply with the company’s return-to-work policy and procedures without authorized exception may subject the employee to disciplinary action.  All employees are responsible for reading and understanding this company’s policy and procedures for return-to-work and discussing any questions or concerns with management. Employee Name: ______________________________ Employee Signature: ______________________ Date: ________

Return to Work Letter - SAMPLE

Instructions for Employer: This is to be sent by the employer to employee with a copy of the doctor’s release via regular and certified mail. Please be sure to copy your insurance company.

A reasonable time has to be given for the employee to show up timely for light duty work.

__________ (Date)

________________ ________________ ________________ (Address)

Dear

We are pleased to learn that you have been released to return to employment at ____________. According to _________________, you are able to return to ____ duty position. Such a position is available at _____________________, the details of which are as follows: Position Title: ________________________________________________ Job Description: ______________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Date to Report to Work: ________________________________________ Location to Report to: _________________________________________ Person to Report to: ___________________________________________ Time to Report: ______________________________________________ Schedule as Follows: __________________________________________ __________________________________________

Wage rate: ____________

We are pleased to be able to offer you this position within the work guidelines established by

___________________________________________________________________.

If you have any questions prior to your start date, please call me at _____________________.

Very truly yours,

Owner/Operator Sample Transition To Full Duty - Jobs by Classification Classification Definition Sedentary-type work

Sedentary-type work includes lifting 10 pounds (4.5 kilograms) maximum. This work involves sitting, occasional walking, standing, and wrapping and packaging finished food products, such as hamburgers and fries. The following positions would be considered sedentary-type work: - Drive-thru or front counter order-taker cashier - Assemble Kids Meals Boxes - Office work, phone calls, and other administrative tasks Light work involves lifting 20 pounds (9.1 kilograms) maximum, with frequent lifting or carrying up to 10 pounds (4.5 kilograms). These jobs also include a small degree of pushing and pulling of arm and leg controls, and walking or standing, some to a significant degree. The following positions are light- work positions: - Runner - Milkshakes and soft serve preparation - Fry station - Production caller - Biscuit preparation - Salad assembly - Setup transition or service - Hotcakes preparation - Host or hostess Medium work involves lifting 50 pounds (22.7 kilograms) maximum, with frequent lifting or carrying of objects weighing up to 25 pounds (11.3 kilograms). These jobs

Light work

Medium work

include the following: - All grill area positions - Grill setup or transition - Dining room and restroom pre-close and close - Service pre-close and close - Back room pre-close and close

Heavy Work

This work should involve 2 or more people Heavy work involves lifting 100 pounds (45.4 kilograms) maximum with frequent lifting, or carrying objects weighing up to 50 pounds (22.7 kilograms) these positions include the following: - Maintenance - Stocking of shelves - Filling tea

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