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N.C. Department of Environment and Natural Resources

NC Department of Environment and Natural Resources
Water Quality - Incident Reporting

Water Quality

 

Our Location:

 Suite 742
(7th Floor Northwest)

Archdale Building

512 N Salisbury Street

Raleigh, NC 27604

 

Our Mailing Address:

 

Staff Services Office

1617 Mail Service Center

Raleigh, NC 27699-1617

 

Fax: (919) 807-6490

 

 

How to report an injury incident

 

The State of North Carolina maintains Worker's Compensation coverage for all employees of the Division. This coverage is provided through a self-funded program and is administered by CorVel, Inc. of Charlotte.  The Worker's Compensation Act establishes three conditions that MUST be met for an injury or illness to be considered compensable.   These conditions are that the employee must suffer a personal injury by accident, that the injury must arise out of, and, in the course of employment with the State.  This means the injured party must be an employee of the State at the time of the incident and the employee must be performing a job duty at the time of the incident, so intentional injuries are not covered.
 

The Office of State Personnel has developed a Worker's Compensation Handbook that is useful for employees to review.  The handbook provides information on each employee's rights and responsibilities under the program.

 

If three (3) or more persons are hospitalized or an employee death occurs, call the Safety Office immediately. 

 

In all other cases follow the reporting process as shown below when an employee is injured while performing his or her duties. 

Immediately following the incident:

  1. Employee must report the incident to his/her supervisor.  If the injury is strictly a tick bite, please log the bite information on this DWQ Tick Incident Form. Multiple embedded ticks during a single day may be put on one incident form.  Submission of this form will constitute first notice to the division.
     
  2. If the incident results in a:
  • life threatening injury, contact the local EMS. 
  • non-life threatening injury, the supervisor is to:

1. Select "Workers Compensation in 'Select a Network' dropdown list, then
2. Insert City, County and 'NC', then
3. Under 'Speciality', scroll down physician list to 'Emergency Medicine', click the "+" sign and     select Urgent Care then press the "Find Providers" button.
4. Inform the provider that an injured employee is on the way to the medical facility and that case is a Worker's Compensation case.  If a preferred medical provider is not available, send employee to a local  medical facility.

  1. provide employee two (2) copies of the Medical Authorization and Pharmacy form (supervisors may sign this form), employee is to distribute the above copies as follows: 
    • give medical provider a copy of Medical Authorization Form and ask that attending physician provide requested physical capability information,
    • if prescription medications are prescribed by the attending physician, provide the 2nd copy of Medical Authorization and Pharmacy form to pharmacy.  The employee is to use one of the authorized pharmacies listed on the bottom of the form.

 

Within 24 hours following the incident:

Supervisor Duties:

  1. Supervisor must notify the Safety Office of the incident and complete the following forms.  The forms are to be returned to the Safety Office via the Section Chief:

The NCIC 19 form can be initially sent via email, but must be followed by a signed copy via interoffice mail, scan/email or fax.

  1. All incidents are to be investigated to determine whether any work processes or procedures need to be changed to remove or reduce the likelihood of repeat incidents.  Process changes are to be noted on the Incident Investigation Form. 

 

Employee Responsibilities:

  • The employee is to fill out the WC Release of Information form and provide a copy to the Safety Office. The employee may keep a copy for his/her records.
  • The employee is to fill out the Employee Statement.  The employee is to provide a statement of what happened
  • The employee is to fill out the Leave Options form to indicate how any days away from work are to be handled.  The supervisor is to fill-in the appropriate blocks on the second page of this form, then sign and date the form then forward the form to the Safety Office. 

 

Incident Follow-up and employee return to work

The supervisor must maintain contact with the employee while the employee is away from work and/or recuperating from the injury.

Upon employee return to work, the employee must provide to the supervisor:

  • Physician completed Return to Work notice with any job restrictions indicated.
  • Physician note specifying reason for days away from work (past or future). If days away are specified by the Physician, employee cannot perform any work-related activities unless those activities have been approved by the Physician.
  • The Safety Office must have a copy of these documents in the incident file.

The Supervisor must keep the Safety Office informed of any days away from work and any work restrictions placed on the employee by the attending physician.

If the attending physician indicates job restrictions, these must be accommodated for the period of time indicated.  For information on the DENR return to work program, contact the Safety Office.

If the employee has out of pocket expenses for prescriptions, reimbursement is to be made on NCIC form 25P (Excel file) and then submitted to the Safety Office.

The maximum weekly benefit for any claim effective January 1, 2012 is $862.00.

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