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 that intentional injuries are not covered, that the injured party must be an employee of the State at the time of the incident and that the employee must be performing a job duty at the time of the incident.
 

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:

Step 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.

Step 2:

Supervisor is to make an injury severity determination.  If the incident is a life threatening injury, contact the local EMS or take directly to the closest hospital.

If the injury is a non-life threatening injury, the supervisor is to:

• call a DENR preferred medical provider in the preferred provider network 

1. (select "Workers Compensation in 'Select a Network' dropdown list, then
2. insert County and 'NC', then
3. scroll down physician list to 'Emergency Medicine', click "+" and select Urgent Care and
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.

• provide employee two (2) copies of the Medical Authorization and Pharmacy form,

Step 3:

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, and
• if prescription medications are prescribed by attending physician, provide the 2nd copy of Medical Authorization and Pharmacy form to pharmacy.  The employee is to use a authorized pharmacy which are listed on the bottom of the form.

 Within 24 hours following the incident:

Supervisor Duties:

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:

• Industrial Commission Form 19 The following parts of the Form 19 will be completed by the Safety Office:
  Questions 10, 11, 15 and 17 and OSHA 301 Information block
• Incident Investigation Form 

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.

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 Supervisor's Accident Report Form. 

Employee Duties:

The employee is to fill out the WC Release of Information form and provide the original to the Safety Office. The employee may keep a copy for his/her records.

If the injury results in any days away from work, the employee shall complete the Employee Statement.  The employee is to provide a statement of what happened, and if necessary, how the initial days away from work will be counted on the Leave Options form.  The supervisor is to fill-in the appropriate blocks on the second page, 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.

When the claim is complete or when requested, send the form to the Safety Office.

If 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 effective January 1, 2010 is $834.00.