Workers Compensation Manager s Guide. Human Resources Contacts

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1 Location: Preferred Provider Clinic: Workers Compensation Manager s Guide Activity Checklist: o PM secures medical treatment or first aid for the injured employee immediately. o o o o o o PM directs the employee to the designated clinic, if the state permits PM provides the employee with a copy of the Authorization for Initial Medical Treatment form and sends the employee to the clinic for treatment PM faxes or s the First Report of Injury (FNOL) to the HR BP within 24 hours PM faxes or s any medical paperwork provided by the employee PM instructs the employee to return to the office after the doctor s visit or as soon as possible with the medical paperwork provided by the physician. The Property Manager and Maintenance Supervisor (if applicable), will complete the Incident Report Form Supervisor s Responsibilities: Report ALL injuries immediately to Human Resources. Treat employees with concern and respect. Accompany the employee to the appropriate medical provider, if necessary. Note: If it is after hours or the weekend, be sure a phone message is left for the HR BP. Ensure employees are not asked to work beyond the restrictions established by the treating physician. Work with your HR BP to strategize how to accommodate return-to-work restrictions reasonably and promptly. Human Resources Contacts California, CO., & North East Maritza Riquelmy Director of HR (813) Florida Denise Vining HR Business Partner (813)

2 Authorization for Initial Medical Treatment The referenced employee has reported sustaining a work-related injury/illness. You are authorized to provide reasonable and necessary treatment for conditions related to the reported injury/illness. Your charges for reasonable and customary services related to the work injury will be paid, per the workers compensation reasonable and customary billing guidelines for your state. Follow-up care and/or referral to specialist will require authorization from our workers compensation insurance carrier. To facilitate prompt payment, a complete copy of this form should be attached to your completed billing document and submitted to: Sedgwick Claims Management Services, Inc. Policy Number: SW1WC Phone Number: Billing Address: PO Box Lexington, KY Should you need to contact the Human Resources Department of the Employer, please call: (All Locations) RICHMAN PROPERTY SERVICES, INC. HAS VARIOUS TRANSITIONAL DUTY POSITIONS AND WILL ASSIST THE EMPLOYEE IN RETURNING TO WORK, IF AT ALL POSSIBLE, EVEN IN A LIMITED CAPACITY. DATE: TO BE COMPLETED BY THE EMPLOYER FROM: Richman Property Services, Inc. TO: NAME OF HOSPITAL, CLINIC, OR DOCTOR: PHONE NUMBER: HUMAN RESOURES BUSINESS PARTNER: Maritza Riquelmy-Romero Denise Vining ADDRESS: 4350 W Cypress Street Suite 340 Tampa, FL PHONE NUMBER: (All Locations) ASSOCIATE NAME: FAX NUMBER: (All Locations) REPORTED INJURY/ILLNESS AND PART OF BODY: 4350 W Cypress Street Suite 340 Tampa, FL 33607

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4 Incident Statement Form Instructions The injured employee and any witnesses to the incident will complete the below form within 24 hours of the incident. Please fill in all of the grey fields below with as much detail and accuracy as possible. Employee/Witness Data Employee/Witness Name Employee/Witness Title Date of Incident Time of Incident Property/Division a.m. p.m. Place of Incident (if different from customary Property / Work Location) Employee/Witness Phone Number Incident Description: 1. Describe the work being performed at the time of the incident. Detail where on the property the incident occurred, the names of people involved, the equipment being used and any weather conditions / structural hazards that may have played a role in the incident. 2. Describe the events that led up to the incident. Describe the sequence in order and when they took place, as you witnessed them. 3. Describe the body part(s) that were impacted by the incident or indicate no injury occurred (near miss). Additional Information Provide any additional information important to the investigation (pictures taken, evidence collected, etc.). Employee/Witness Acknowledgement: Employee/Witness Name (Print) Employee/Witness Signature Date

5 Incident Investigation Report Form Instructions An Incident Investigation is to be conducted whenever an employee is injured on the job or when there is a near miss that could have resulted in bodily injury to an employee. The Property Manager and Maintenance Supervisor (if applicable) will conduct the Incident Investigation. If the Property Manager is injured, the Regional Manager will conduct the investigation. An Incident Statement Form is to be completed by the injured employee and any witnesses. They are to include what happened and what caused the incident. Attach additional sheets if necessary. Provide copies of the completed form and all Incident Statement Forms to: Regional Manager, Maintenance Operations Manager and Human Resource Business Partner. The Incident Investigation Report Form is to be submitted by the end of the business week in which the incident happened or 5 calendar days following the date of the incident. Please fill in all of the grey fields below with as much detail and accuracy as possible. Injured Employee Data Employee Name Employee Title Direct Supervisor Date of Incident Time of Incident Property/Division a.m. p.m. Place of Incident (if different from customary Property / Work Location) Property Manager Location Phone Number Employee Phone Number Incident Description: 1. Describe the work being performed at the time of the incident. Detail where on the property the incident occurred, the names of witnesses or coworkers involved, the equipment being used and any weather conditions / structural hazards that may have played a role in the incident. 2. Describe the events that led up to the incident. Describe the sequence in order and when they took place. 3. Describe the extent of the injuries. Include the affected body part(s) and injury type or indicate no injury occurred (near miss). Training and Supervision: The intent of this section is to determine if adequate safety and safe work methods training was provided regarding the task that led to the incident. Also, to determine if adequate supervision was provided to ensure that safe work methods and safety practices were adhered to. 1. Was the employee trained to safely complete the task that led to the injury? (Yes/No) If yes, how so? 2. Was adequate supervision provided to ensure that safe work methods were adhered to? (Yes/No) If yes, how so? 1

6 Incident Investigation Report Form Task Assessment: The intent of this section is to review the method in which the task is accomplished and strategizing if there are alternative methods to ensure safety. Is there is a safer, alternative approach(es) to complete the task or avoid/postpone the task until it can be done safely? (Yes/No) Please explain in detail: Tools, Equipment and Materials: The intent of this section is to determine if the choice and the use of tools, equipment or hazardous materials were a contributing factor in the incident. 1. Did the employee use/have the right tools to complete the task? (Yes/No) If no, please explain: 2. Did the employee use the tools and equipment as designed and intended? (Yes/No) If no, please explain: 3. Could the employee have used safer, less hazardous materials? (Yes/No) If no, please explain: Additional Information Provide any additional information important to the investigation (pictures taken, evidence collected, etc.). Initial Investigator: Incident Investigator Name Date of Investigation Time of Investigation a.m. p.m. 2

7 Incident Investigation Report Form CHECK ALL CAUSES THAT MAY HAVE CONTRIBUTED TO INCIDENT Training Safety Program/Policy Doesn t Address Hazard Hazardous Material Safety Training Not Provided Safety Refresher Training Not Provided Safety Training Inadequate No Standard Operating Procedure (SOP) Training No Safe Operation of Equipment Procedures Posted Other Supervision Safety Training Not Assigned Inadequate enforcement of safety policy Routine inspections of work areas not conducted Other _ Supervisor condoned unsafe act Defective Equipment not Replaced despite request Tools and Equipment Correct tool/equipment not available Equipment used improperly Failure/circumvent guards Failure to use the right tool/equipment Used Defective Equipment PPE not available Failure to use PPE Inadequate Preventive Maintenance Unsafe/poor equipment set-up Other _ Materials Incompatible materials Improper/unsafe materials handling Unsafe/poor material storage Improper/insufficient labeling Other _ Other factors Not Adhering to Job Instructions Poor Work Practice Inadequate Purchasing Standards Inadequate Purchasing Standards Lack of Skill Improper Extension of Service Life Lack of Communication Between Staff Improper Planning Inadequate Cleaning Inadequate Preventive Maintenance Other CHECK ALL ACTIONS NECESSARY TO CORRECT THE CAUSES Task Analysis/Procedure Revision Improve Clean-Up Procedures Repair/Replace Equipment Reinstruction of Employees Improve Storage/Arrangement Rotation of Employee Eliminate Congestion Improve/Change Work Method Identify/Improve PPE Task Analysis to Be Completed Install/Revise Guards/Devices Improve Enforcement Job Reassignment of Employees Use Other Materials/Supplies Improve Illumination Mandatory Pre-Job Instructions Other Improve Ventilation Recommended corrective actions or preventive measures to be taken Action Item Person Responsible Target Date Date Complete Investigation Review (Initial after reviewing the findings of the investigation): Initials Review Date Comments Direct Supervisor Property Manager Reginal Manager Maint. Operations Manager 3

8 Incident Investigation Report Form HR Business Partner 4

9 Workers' Compensation In-Network Providers Policy Number: SW1WC Name Specialty Address City County State Zip Phone Fax Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 1419 Knecht Ave Baltimore Baltimore MD Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 1833 Portal St Baltimore Baltimore MD Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 8101 Pulaski Hwy Baltimore Baltimore MD Patient First Maryland Medical Group, Pllc - Maryland Urgent Care Clinic 8830 Belair Rd Baltimore Baltimore MD Patient First Maryland Medical Group, Pllc - Maryland Urgent Care Clinic 5100 Eastern Ave Baltimore Baltimore MD Patient First Maryland Medical Group, Pllc - Maryland Urgent Care Clinic 4924 Campbell Blvd Baltimore Baltimore MD Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 100 S Charles St Baltimore Baltimore City MD Concentra Medical Center Occupational Medicine 1833 Portal St Baltimore Baltimore MD Concentra Medical Center Occupational Medicine 8101 Pulaski Hwy Baltimore Baltimore MD Concentra Medical Center Occupational Medicine 1419 Knecht Ave Baltimore Baltimore MD Medstar Promptcare Urgent Care Clinic 6317 York Rd Baltimore Baltimore MD Patient First Urgent Care Clinic 5100 Eastern Ave Baltimore Baltimore MD Concentra Medical Center Occupational Medicine 100 S Charles St Baltimore Baltimore City MD Medstar Promptcare Urgent Care Clinic 1420 Key Hwy Baltimore Baltimore City MD Express Care Urgent Care Centers Urgent Care Clinic 3815 Wilkens Ave Baltimore Baltimore MD Express Care Urgent Care Centers Urgent Care Clinic 7700 Belair Rd Baltimore Baltimore MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 1419 Knecht Ave Baltimore Baltimore MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 1833 Portal St Baltimore Baltimore MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 8101 Pulaski Hwy Baltimore Baltimore MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 100 S Charles St Baltimore Baltimore City MD Franklin Square Hospital Center Occupational Medicine 9000 Franklin Square Dr Baltimore Baltimore MD St. Agnes Hospital Occupational Medicine 900 Caton Ave Baltimore Baltimore MD Euster, Caren, MD Occupational Medicine 600 N Wolfe St Baltimore Baltimore City MD Weaver, Virginia M., MD Occupational Medicine 600 N Wolfe St Baltimore Baltimore City MD Schwartz, Brian S., MD Occupational Medicine 4940 Eastern Ave Baltimore Baltimore MD Amr, Sania, MD Occupational Medicine 29 S Paca St Baltimore Baltimore City MD Schwartz, Brian S., MD Occupational Medicine 600 N Wolfe St Baltimore Baltimore City MD Harbor Hospital Center Occupational Medicine 3001 S Hanover St Baltimore Anne Arundel MD Good Samaritan Hospital Occupational Medicine 5601 Loch Raven Blvd Baltimore Baltimore MD Union Memorial Hospital Occupational Medicine 201 E University Pkwy Baltimore Baltimore City MD University Of Maryland Medical Center Midtown Campus Occupational Medicine 827 Linden Ave Baltimore Baltimore City MD Express Care Urgent Care Centers Urgent Care Clinic 6000 Laurel Bowie Rd Bowie Prince George`s MD Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 9141 Alaking Ct Capitol Heights Prince George`s MD Concentra Medical Center Occupational Medicine 9141 Alaking Ct Capitol Heights Prince George`s MD Concentra Health Systems (Wc Only) Occupational Medicine 9141 Alaking Ct Capitol Heights Prince George`s MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 9141 Alaking Ct Capitol Heights Prince George`s MD Patient First Clinton Urgent Care Clinic 9000 Woodyard Rd Clinton Prince George`s MD Medstar Southern Maryland Hospital Center, Inc Occupational Medicine 7503 Surratts Rd Clinton Prince George`s MD Carroll Occupational Health Llc Occupational Medicine 490 Prospect Blvd Frederick Frederick MD Mann, Stephan Charles Boyd Occupational Medicine 490 Prospect Blvd Frederick Frederick MD Piacentino, John D. Occupational Medicine 490 Prospect Blvd Frederick Frederick MD Swanson-Apollon, Jocelyn E. Occupational Medicine 1305 W 7th St Frederick Frederick MD Pm Pediatrics Urgent Care Clinic 7401 Greenbelt Rd Greenbelt Prince George`s MD Concentra Medical Centers - Occupational Health Centers of the Southwest Occupational Medicine 4451 Parliament Pl Lanham Prince George`s MD Concentra Medical Center Occupational Medicine 4451 Parliament Pl Lanham Prince George`s MD Concentra Medical Centers - Us Medgroup, Pa Occupational Medicine 4451 Parliament Pl Lanham Prince George`s MD Doctors Community Hospital Occupational Medicine 8118 Good Luck Rd Lanham Prince George`s MD My Care Urgent Care Urgent Care Clinic 8500 Annapolis Rd New Carrollton Prince George`s MD Urgent Care Matters Urgent Care Clinic 5474 Saint Barnabas Rd Oxon Hill Prince George`s MD

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13 Medical Treatment Waiver Richman Property Services, Inc. is concerned with every employee s well-being. In the event you elect not to seek medical attention, we need to document that Richman Property Services, Inc. has not influenced, in any way, your decision to not seek treatment. Employee: Date of Injury: Description of Accident: Description of Injury My signature confirms that I have voluntarily waived medical care due to the injury indicated above. Should it later be determined that I require medical care, I will consult with my Injury Counselor prior to seeking treatment, unless emergency treatment is required. Employee s Signature: Date: A signed copy of this form should be given to the employee.

14 Renuncia de Tratamiento Medico (Nombre de la Compania) se interesa en el bienestar de todos sus empleados. En el caso que usted no desee recibir tratamiento medico, necesitamos documenta que (Nombre de la Compania) no ha influido en ninguna forma su decision de no solicitor tratamiento medico. Empleado: Fecha del Incidente: Descripcion del Incidente: Descripcion de la Herida: Mi firma es confirmacion de que he voluntariamente renunciado tratamiento medico para el antedicho incidente. Si se determina que necesito tratamiento medico, consultare con mi Injury Counselor antest de solicitor tratamiento, a menos que se requiera tratamiento medico de emergencia. Firma del Empleado: Fecha: