RETURN-TO-WORK PROGRAM POLICY STATEMENT It is the policy of ____________ to maintain and support a Return-to-Work Program. It is designed to minimize the disruption and uncertainty that can accompany any injury or illness for both ____________ and for all its employees. The cornerstone of this Return-to-Work Program is communication. As such, a specific responsibility for communicating return-to-work information is central to its success and is the basis for this program. PROCEDURES I. As soon as possible after an injury* occurs the worker should report the injury to his/her ____________ who in turn will report it to ____________. This should be accomplished within 24-hours. Any necessary paperwork will be provided and, if necessary, assistance given for completing it. All appropriate information will be submitted to SAFECO Insurance Companies, including all return-to-work information. The worker will be provided with a copy of “Worker Responsibilities When Injured On the Job” when an injury is reported. While off work with an injury contact with ____________ should be maintained as follows: A. The worker is to report his/her return-to-work status after each doctor’s appointment. Unless otherwise arranged between the worker and _____________, this shall be done in person by providing a copy of a work release, a physical capacity form or a job analysis signed by the attending physician. The worker should contact _____________ by telephone or in person each This contact is intended to keep the worker informed of pertinent company information and the company informed of the worker’s current condition/needs for return-to-work. If ____________ is unavailable, the alternate contact would be ____________. II. III. B. C. IV. If the worker leaves work to see a physician he/she is to relay information to the physician regarding the availability of transitional work. The communication of this information may done in writing or verbally. In any event, when the attending physician is known, information regarding available transitional, either in the form of a specific job analysis/task list or a request for physical capacity information, will be provided. A job analysis for the worker’s regular job also will be provided if one is available. This may be done by ____________, SAFECO Insurance Companies or both. V. The worker will be assigned to a job or task(s) according to the restrictions/approval of the attending physician and the business needs of ____________ at the time of the release. This assignment may be in a different department or on a different shift than worked at the time of injury. It may be a portion of the regular job if the restrictions require a reduction in hours or the elimination /reassignment of a work activity/activities essential to the performance of the job. Transitional jobs are temporary in nature and are intended to ease the employee back to regular duty. The transitional work will be monitored by ____________ on an on-going basis. Should the attending physician change the worker’s restrictions, the transitional assignment may be adjusted accordingly. In any case, workers will not be expected to exceed the restrictions given. If the transitional assignment lasts for more than (14 days), it will be reviewed at that time and at (14-day) intervals thereafter. It may be extended or ended at the discretion of ____________. Any problems with the transitional assignment will be discussed with the worker and any changes needed will be defined. VII. When the attending physician gives a release to transitional work, a job offer letter may be given in person or mailed CERTIFIED mail, with a response requested. It shall include a description of the job duties, the start date and hours, the duration of the job (if known), where and to whom to report, the wage to be paid and a copy of the work release and/or signed job analysis. The transitional job will end when whichever of the following occurs first: A. B. C. the worker is released for full duty regular employment; the worker returns to a job that is not part of the Return-to-Work Program; the transitional job is no longer available or has not been extended under the terms of this program; or the workers’ compensation claim is closed. VI. VIII. D. IX. Should the worker be given permanent restrictions by his/her attending physician, each case will be reviewed individually outside this Return-to-Work Program and in accordance with all state and federal guidelines. * For the purpose of this Return-to-Work Program, an “injury” also includes an occupational disease as defined by the governing state workers’ compensation statutes. Company name or position title. Names change titles do not.