Reporting Procedures
Workers compensation is provided to employees in the event of death, injury, or occupational disease occurring during the course of their employment. An incident must first be reported to the claimants immediate supervisor, and documented on the Accident or Illness Report (ADM 4303).
When medical attention is necessitated, the employee and supervisor need to obtain the Work Related Injury or Accident Reporting Procedure Packets from the division/office workers comp designee (WCD). Each party needs to follow the instructions enclosed in the packet and have the Initial Physician Report completed by the appropriate parties. It is essential for the completed ADM4303 to be returned to the division/office WCD as soon as possible. To ensure prompt notification of the injury/accident the division/office WCD is responsible for faxing the completed ADM 4303 to the Office of Human Resources (OHR) within 24 hours. The original ADM 4303 needs to be forwarded to the Office of Human Resources who will fax the completed ADM 4303 to the MCO (Managed Care Organization). It is the attending physicians responsibility to fax the Initial Physician Report to the MCO within twenty-four (24) hours of treatment. In cases of lost time, the Wage Statement (C-94-A), the Calendar of Wages Paid (ADM 4741), and the Wage Agreement (if applicable) need to be completed by the division/office WCD and submitted to OHR as soon as an employee meets the lost time requirements.
The Department of Administrative Services, Benefits Section, has the responsibility of administering state employee industrial injury or occupational disease claims. The Department of Administrative Services is the only agency authorized to review and certify claims as the employer for the State of Ohio.
As soon as the Benefits Section receives the completed forms, the claim will be processed. The Bureau of Workers Compensation advises the claimant in writing of the claim number to be used in conjunction with the injury.
Forms to be Used When Filing a Claim
Accident or Illness Report (ADM 4303): The ADM 4303 must be completed in its entirety by the employee and the immediate supervisor on the day of the accident if at all possible. It must be signed and dated by both parties. The division/office WCD is responsible for reviewing the workers compensation claims, faxing the completed ADM 4303 to the Office of Human Resources, and forwarding the originals to OHR.
The ADM 4303 provides proof of an incident occurring and being reported to the proper parties. It is important to remember that not all incidents result in injury and not all injuries result in disability. Therefore, the ADM 4303 must be retained by the employer to maintain a record of the incident until a BWC claim is filed. If a BWC claim is not filed, the ADM 4303 should be retained for at least two (2) years, the length of time an employee has to file a BWC claim application for that injury.
Initial Physician Report: This Managed Care Organization (MCO) form needs to be completed in its entirety, the detail of which parties are responsible for each section are listed below:
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Section
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Responsible Party
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Injured Worker
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Employee
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Injury/Disease/Death
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Attending Physician
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Employer Information
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Division/Office WCD
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Physician Data
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Attending Physician
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Treatment Plan
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Attending Physician
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Vague medical findings can result in delays. The physician should state the objective and subjective findings.
Wage Statement (C-94-A): In an instance when an injury results in lost time (more than seven (7) consecutive days off) the wage statement must be completed by the division/office WCD. These figures will be used to calculate the temporary total benefits to be paid by the BWC.
Calendar of Wages Paid (ADM 4741): Form completed by the division/office WCD detailing the days off and the type of leaves used for each day. Only used in lost time claims.
Coverage for Workers Compensation Waiting Period (WC7-40)
: The AFSCME/OCSEA Contract, Article 34.02 states that employees in the bargaining unit shall be allowed full pay during the first seven consecutive days of absence. This form is used to acknowledge the date and type of leave covered by this language.
Wage Advancement Agreement: This form is used for the purchase of leave used while a workers compensation claim is pending. Only employees covered by AFSCME/OCSEA Units 3,4,5,6,7,9,13,14, and 1199 contracts may participate in a leave buy back. This form is optional.
Supplemental and Reactivation Forms: Request for Temporary Total Compensation (C-84): This is the form used as medical evidence to support continued temporary total disability benefits. This form should be filed prior to the expiration of the existing award. It is used as a basis for extending or requesting temporary total compensation. This form is also completed to request additional compensation and/or further medical treatment for a reactivation of an injury. This form is required when a claim has become inactive. It is generally filed when there has not been activity on the claim for 1 ½ to 2 years.
Lost Time Claims
A maximum of four (4) weeks of compensation can be paid before additional medical is required. Compensation (temporary total) can be paid only upon submission of a report by the attending physician certifying the claimant to be unable to work as a result of the allowed injury.
The injured employee may use accumulated leave, and/or request payment for loss of time under the Workers Compensation Act. Vacation and personal leave may be paid over the same period as workers compensation benefits. However, sick leave and temporary total cannot be paid over the same period of disability unless the employee completes a Wage Agreement Form. The Wage Agreement Form is limited to employees covered by AFSCME/OCSEA Units 3,4,6,7,9,13,14, and Ohio Health Care 1199 contracts.
It is important to complete the Wage Statement (C-94-A) indicating the employees wage for the year prior to the injury date. The ADM4741 must be completed detailing the dates and types of leave used while the employee workers compensation lost time benefits is pending. These forms are needed by the examiners at the Bureau of Workers Compensation to determine what dates are compensable.
If the employee is in a bargaining unit which entitles him/her to 100% payment of the first seven (7) days of disability due to a work related incident, this payment should be included on the calendar as wages. For an OCSEA bargaining unit member, a claim does not constitute lost time benefits paid from the BWC until an employee has missed 14 consecutive days. This is due to the collective bargaining contract covering the waiting period of its members.
The Bureau of Workers Compensation will pay the first twelve (12) weeks of benefits based on the full weekly wages (FWW). After twelve (12) weeks, the Bureau of Workers Compensation pays according to the average weekly wage (AWW). AWW is determined by dividing the total earnings in the 52 weeks prior to the date of injury by 52. Employees will receive 66 2/3% of the AWW each week.
Leave Buy Back
Leave buy back is limited to employees covered by AFSCME/OCSEA Units 3, 4, 5, 6, 7, 9, 13, 14, and the Ohio Health Care 1199 contracts. This benefit is not currently available under any other bargaining unit agreement nor for exempt employees. It is also limited to injuries occurring on or after March 1, 1992.
Eligible employees who file for BWC lost time wages have two (2) options for buying their time back:
- They may use leave balances while awaiting a determination of their workers compensation claim without signing an agreement form, or;
- They may use leave balances as referenced in Option #1 but sign a Wage Advancement Agreement form before using such leave balances.
The distinctions between the options are explained below.
Option #1, Without an Agreement Form:
This option involves employees who use their leave balances while awaiting a determination on their workers compensation claim but either fail to, or elect not to, file a wage advancement at the time they file their application for BWC lost time wages. However, if sick leave is used with this option, the BWC will not pay temporary total benefits over the same time period. Therefore, if an employee wants to use sick leave and be paid BWC benefits for the same timeframe then it is necessary to sign a Wage Advancement Agreement or use other forms of leave while the BWC benefits are pending.
When temporary total wage benefits have been paid by BWC, the employee will have the option to buy back any portion of the leave balances used which overlap the date BWC paid temporary total benefits. The type and quantity of leave time purchased is solely at the discretion of the employee. This option is limited to the first twelve (12) weeks for which the employee received weekly wage benefits from BWC. The employee must buy back the leave within two (2) pay periods after the receipt of the BWC payment.
The employee is not obligated to buy back all the leave time used nor is the employee obligated to purchase the leave time in any particular order. However, sick leave cannot be bought back under this option because temporary total wage benefits are not awarded over the same dates an employee uses sick leave. If the employee wishes to purchase more leave than their BWC check permits, they may submit a personal check made out to the Department of Natural Resources for the remainder of the time available.
Option #2, With an Agreement Form:
This option involves employees who use leave balances while awaiting a determination on their workers compensation claim but submit a signed Wage Advancement Agreement form with their application for BWC lost time wages. The agreement provides that the agency will advance the employee accrued leave balances and the employee will reimburse the agency to the extent the employee was paid by BWC over the same period of time. With the agreement form option, the employee has a limited choice as to the type and quantity of leave time to be restored. Sick leave must be restored first. The employee may then choose the order of any other type of leave to be restored. Restoration under this option is also limited to the first twelve (12) weeks for which the employee received weekly wage benefits from BWC.
The leave must be restored to the full extent permitted by the BWC award. The employee does not have the option to have less time restored than the award permits. Since the BWC award should never cover the entire twelve-week period, the employee does have the option to submit a personal check made out to the Department of Natural Resources for the remaining time available.
BWC will pay over the date sick leave was used because we will provide the Bureau of Workers Compensation with prior notification that sick leave was paid as an advancement per the agreement form. Such prior notification cannot be provided without a signed agreement form.
The Wage Advancement Agreement Form is attached.
In General:
To buy back leave or reimburse an advancement, the BWC award will be issued to the employee and the Department. It is necessary for the employee to endorse the BWC check over to the agency. If the employee wishes to purchase all the leave used they must submit a check or money order payable to the agency for the remaining balance. Once the money is deposited the OHR will reinstate the appropriate leave.
Transitional Work Policy
Per Article 34.05 of the OCSEA contract agencies and the Union may mutually develop transitional work programs designed to encourage a return to work by an employee receiving workers compensation benefits or Occupational Injury Leave (OIL). During the time an employee is in a transitional work program, the employee will be assigned duties which the employee is capable of performing based upon the recommendation of the employees attending physician. Upon request of the Employer employees must participate in the transitional work program unless precluded from participation by their attending physician. Please refer to the Ohio Department of Natural Resources Transitional Work Policy.
Disability Leave Benefits Program and Workers Compensation
Disability Leave Benefits can be applied for only if the employee's Workers' Compensation Form has been denied. Please contact your Human Resource Professional.
Hearing and Appeal
Where a controversy exists over a claim, the claim is considered "contested" by either the employer, claimant or the Bureau.
Initially, hearings are set before a District Hearing Officer to decide the matter that is being contested. The District Hearing Officer issues his decision called an "order".
If either party is dissatisfied, they may file an appeal (IC-12). The appeal must be filed within fourteen (14) calendar days of receipt of the order from the District Hearing Officer. Normally, the appeal goes to the three member Regional Board of Review in the area that includes the district handling the claim. The Regional Board issues their order after a hearing.
If either party is dissatisfied with the Regional Board of Review order, they may file an appeal within fourteen (14) days. This appeal is then heard by the Industrial Commission, or two staff hearing officers on behalf of the Commission. The Industrial Commission may refuse to hear the appeal or may set it for hearing. An order of refusal will be issued if they refuse the appeal. If they hear the appeal, an order from the Commission will be issued as to their decision. In either case, appeal by either party may be taken to Common Pleas Court within sixty (60) days from receipt of the I.C. order on the merits or refusal to consider the appeal. This appeal must be filed within the Court of Common Pleas in the county in which the employee was injured.
Obtaining Claim Forms
All forms (except ADM 4303 and ADM 4741) may be obtained from:
Bureau of Workers Compensation
Attention: Officer Services
246 N. High St.
Columbus, OH 43266-0581
Forms ADM 4303 and ADM 4741 may be obtained from:
Department of Administrative Services
State Forms Distribution
4200 Surface Road
Columbus, Ohio 43228-1395
(614) 466-2396
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