<CompanyName>

Transitional Work Program

Policy & Procedures

TABLE OF CONTENTS

Policy Statement	3

Program Benefits	4

Benefits for our employees	4

Benefits for <CompanyName>	4

Return to Work Procedures	5

Report all injuries/illnesses

Identifying Transitional Work Tasks	5

Obtain a medical release	5

Return to work status	6-7

TWA guidelines	7

Disability classifications	8

Medical Treatment	8

Employee Acknowledgment	9

Return to Work Templates & Forms	10-15

Letter to the employee …………………………………………………………………………………………………….…..10

Letter to the attending physician…………………………….....………………………………………………………..11

Task Identification Form.………………………………………………………………………………….…………………..12

Transitional Work Task Physical Capacities Form …………………………………………..……….…………...13

Transitional Work Task List ………………………………………………………………………….………….………..…14

Notice of Transitional Work Assignment (TWA) ……………………………………………..…………………….15

POLICY STATEMENT

<CompanyName> employees can become injured on the job or develop work-related illnesses, which may temporarily or permanently limit their ability to perform the full scope of their regular job duties. Our goal is to assist in the recovery process, by returning our injured employees to productive employment at the earliest possible date following a work-related accident or illness.

Whenever possible, we will offer Transitional Work Assignments (TWAs) to employees released to return to modified duty by their attending physician. TWAs will be developed / offered in consideration of the employee’s physical restrictions, the business needs of <CompanyName> and the availability of Transitional Work Duties at the time of release.

We have outlined the Program procedures in the following pages. <CompanyName> may modify the Transitional Work Program at any time to reflect changing business needs.

PROGRAM BENEFITS

The <CompanyName> Transitional Work Program can speed the recovery and return of our injured employees, as well as reduce costs associated with workplace injuries.

Benefits for our employees

Speeds the employee’s return to productive activities.

Shifts focus from disabilities to abilities.

Increases the employee’s self-esteem.

Provides a sense of job security.

Shows we value our employee’s contributions.

Allows the employee to maintain contact and rapport with staff and co-workers.

Keeps the employee active and speeds medical recovery.

May reduce risks of re-injury by changing old behaviors.

Benefits for <CompanyName>

Returns injured employees to work.

Maintains the services and skills of trained employees.

Cuts costs associated with hiring and training new personnel.

Reduces medical and time-loss costs, which affect future premiums.

Identifies and reduces potential injuries among other employees.

Maintains the employee/employer relationship.

Provides a resource to complete tasks that may be a low priority or otherwise overlooked.

May reduce the risk of re-injury through behavior changes in employees.

RETURN TO WORK PROCEDURES

Report all injuries/illnesses

<ClaimsReporter> should Report All injuries using the ICW Group Online Policyholder Center. Select the correct form for your state to complete prior to the end of the employee’s shift or within 24 hours of the incident.

Call 9-1-1 for all employees needing immediate medical treatment. When appropriate, a manager or designated employee should accompany the injured employee.

Identifying Transitional Work Tasks

In order to facilitate easy return to transitional duty, <CompanyName> will identify a bank of available transitional duty tasks on a semi-annual basis.

Supervisors and managers will conduct a survey twice a year to identify transitional work tasks. Supervisors and managers will complete the Task Identification Form and submit it to <ResponsibleParty>.

<ResponsibleParty> with assistance from our ICW Group Risk Management Consultant, if needed, will complete the Transitional Work Task Physical Capacities Form for each task identified.

Obtain a Release to Transitional Work

If non-emergency medical treatment is required on the day of injury, the employee’s manager, or <ResponsibleParty> will provide the injured employee with the following materials prior to leaving the worksite:

A copy of the Transitional Work Task List, when applicable.

A list of local medical providers.

Injured employees should be verbally instructed by the employee’s manager, or <ResonsibleParty> to:

Inform the attending physician that transitional work is available.

Provide the forms to his/her physician at the time of treatment.

Refer any questions to <ResponsibleParty>.

Obtain a copy of the Work Release form from the Physician at the time of exam.

Failure to report to work or contact a manager within 24 hours following medical treatment may result in disciplinary action.

In an emergency, <ResponsibleParty> should provide the attending physician with the above stated information, as it becomes available.

Return to work status

Release To Work With No Restrictions (Full Release)

Employees treated within their work shift and released to return to work with no restrictions, should report immediately to their manager and submit the completed Medical Release.

If released after the end of a shift, employees should report to their manager at the beginning of their next shift with a completed Medical Release.

In all cases where the attending physician gives an employee a full release to return to work, the employee is required to contact their manager, or <ResponsibleParty> within 24 hours of receipt of medical treatment.

Not able to return to work

If the injured employee cannot report for his/her next scheduled shift, the employee’s manager or <ResponsibleParty> should contact the employee to:

Express concern and find out how he/she is recovering.

Arrange a time and day to maintain weekly contact.

Address the need to report to management within 24 hours of all changes in medical condition.

Discuss the employee’s responsibility to provide current changes of address and phone number(s) to Human Resources.

Management must also notify Human Resources and the ICW Group Claims Examiner by phone or email within 24 hours of knowledge of an employee losing time from work.

The ICW Claims Examiner will begin working with the attending physician. The employee’s manager or <ResponsibleParty> needs to email or fax the Transitional Duty Task List to the ICW Claims Examiner, who will coordinate with the physician to use the Transitional Duty Task List to expedite the employee’s return to productive employment.

Release to Modified Duty

If possible, the employee’s manager, or <ResponsibleParty> should provide the Transitional Work Task List to the injured employee to take to the doctor for approval.

If none of the TWA from existing list are appropriate, identify a TWA based on the employee’s work restrictions.

Upon release to “modified duty”, a written TWA will be prepared by the employee’s manager and <ResponsibleParty> along with a copy of the signed Work Release from the attending physician.

<ResponsibleParty> should send a copy of the Notice of Transitional Work Assignment to the ICW Claims Examiner.

<ResponsibleParty> should arrange a meeting with the employee’s manager to discuss the terms of the TWA and/or send a mailed copy to the employee’s last known address.

<ResponsibleParty> should ask the worker to sign the bottom of the TWA indicating acceptance or refusal of the offered assignment.

TWA guidelines

<CompanyName> will determine appropriate work hours, shifts and locations of all TWAs. We reserve the right to determine the availability and appropriateness of all TWAs.

The Company offer TWAs for two weeks at a time. If the work is still available after two weeks, the assignment will be re-offered. If work ceases to be available, the offer may be rescinded.

TWAs will be reviewed regularly and extended or ended at the discretion of <CompanyName>, based on business needs.

Management will monitor the employee’s recovery progress through regular contact or meetings to reassess when and how often duties may be changed. Upon receipt of increased physical capacities, the manager will assess the ability to adjust the TWA accordingly.

All changes to TWAs will be made after receiving concurrence from the employee’s attending physician.

No changes beyond the previously physician approved work restrictions shall be made.

If the employee is later determined to have a permanent disability, which restricts his/her ability to return to job at time of injury, the TWA may end.

<CompanyName> will determine whether the worker’s physical restrictions require substantial modification to job tasks and whether such modifications are reasonable.

To the extent reasonable, <CompanyName> will consider work site modifications to allow the injured employee to continue employment.

Disability classifications & wage replacement

Your Claims Examiner will determine if the injured employee is entitled to partial wage replacement benefits if there is a difference between the employee’s regular rate of pay and the TWA wages.

Employee’s refusal of a physician approved TWA offer in the form of a verbal refusal or failure to report to work on the scheduled start date of the assignment may result in a reduction or termination of wage replacement benefits to the employee per state law.

Medical Treatment

Medical treatment parameters for work related injuries vary greatly by jurisdiction. Please contact your ICW Group Claims Examiner to learn more about the medical treatment guidelines for your state.

EMPLOYEE ACKNOWLEDGMENT

The Return to Work policy/procedures have been explained to me.

I have read and fully understand all procedures and responsibilities.

I agree to observe and follow these procedures.

I understand that failure to complete my responsibilities may result in disciplinary action up to and including termination.

I understand that failure to follow these procedures may also affect my right to re-employment, reinstatement of rights, or possible future vocational assistance following disability.

Employee Signature: _________________________________________________

Date of Injury:	______________________________________________________

Policy/Procedures provided by: _________________________________________

Today’s Date: _____________	Location #: ________________________________

Letter to Employee

Transitional Work Assignment

Enter Today’s Date

Dear Enter Employee’s Name,

We are sorry to hear that you had an on-the-job injury that may require medical attention and/or involve time away from work. We want to do everything possible to assist in your recovery and speed your return to productive employment.

We can provide better support and process your benefits much faster, if you follow the Transitional Work Program procedures outlined below. Contact your manager for more information about our company’s Transitional Work Program, and a list of medical providers in your area.

Take the attached “Transitional Work Task List” with you to your next scheduled medical exam.

Ask your physician to review the materials and initial the Transitional Work Task List approving your fitness for a transitional work assignment.

If you are released to return to work the same day, provide management with a completed Work Release form when you return.

If you are unable to perform your regular job duties, a Transitional Work Assignment (TWA) will be offered whenever possible. Your physician will evaluate the available tasks to determine whether it’s medically appropriate to return you to transitional duty work.

If you are unable to return to work for your next scheduled shift, immediately call and notify your supervisor, or a member of management.

Have a speedy recovery. We need you, and we look forward to having you back at work!

Regards,

<ResponsibleParty>

Letter to attending Physician

Date: Enter Today’s Date

Enter Physician’s Name

Enter Mailing Address

Re:	Employee Name: Enter Employee’s Name

Claim No.: Enter Claim Number

DOI: Enter DOI

Dear Dr. Enter Physician’s Name:

Thank you for providing medical care to Enter Employee’s Name for Enter his/her Enter Employee’s Name condition.

<CompanyName> offers Transitional Work Assignments to our injured employees who are unable to immediately return to their regular job duties. We can provide transitional work to accommodate most injuries.

Attached is a copy of our Transitional Work Task List. Please identify those tasks Enter Employee’s Name is capable of performing, given their current physical capacities. If none of the identified tasks are acceptable, please complete a functional capacities evaluation to identify what physical capacities Enter Employee’s Name does have and we will work to find transitional work tasks that accommodates those restrictions.

Please fax the requested materials to the number provided below.

Thank you for your cooperation and timely reply.

Sincerely,

<ResponsibleParty>

Fax no.: <CompanyFaxNumber>

c.c.	Enter Employee’s Name

Enter ICW Group Claims Adjustor’s Name

<CompanyName>

Task Identification Form

Manager / Supervisor: Enter Manager’s Name	Department: Enter Dept. Name

Manager or Supervisor: Describe the tasks you would have an extra employee perform for you within your department or area of responsibility. List all the tasks that you can think may need to be completed. (1) For each task (2) identify how many hours a week you feel this task may take an extra employee, (3) list the essential skills and abilities (Skill – computer, telephone, Abilities – climbing, lifting) for the tasks and (4) rate the exertion level as Sedentary, Light, Medium or Heavy.

Task Description (1)	Hours per Week (2)	Essential Skills & Required Body Parts (3)	Exertion Level (4)

<CompanyName>

Transitional Work Task Physical Capacities Form

Task #: Enter Task #	Task Description: Enter Task Description

Employee: Enter Employee’s Name	Date of Birth: Enter Employee’s DOB

None	0-2 Hours	2-4 Hours	4-6 Hours	6-8 Hours
In an 8-hour workday, the employee will stand (total)
In an 8-hour workday, the employee will stand (at one time)
In an 8-hour workday, the employee will sit (total)
In an 8-hour workday, the employee will sit (at one time)
None	10-30 Minutes	30-60 Minutes	1-3 Hours	Over 3 Hours
In an 8-hour workday, the employee will drive car/truck (at one time)
Less than 5 Pounds	5 to 15 Pounds	15-25 Pounds	25 to 50 Pounds	Over 50 Pounds
Employee Can Lift and Carry (max)
Employee Can Lift and Carry (frequently)
Employee Can Lift and Carry (occasionally)
Yes	No
Employee can use hands for repetitive
Simple Grasping
Pushing and Pulling
Fine Manipulation
Yes	No
Employee can use feet for repetitive movement (operating foot control)
Frequently	Occasionally	Not at All
Employee may perform the following:
Bending
Kneeling
Squatting
Climbing
Reaching
Yes	No	Comments
Employee is exposed to environmental factors such as heat/cold, dust, heights, dampness, etc.
Yes	No	Comments
Will treatment or medication affect employee’s ability to perform work?
Yes	No	Comments
Will employee require any assistive devices or braces?

<CompanyName>

Transitional Work Task List

Employee Name: Enter Employee’s Name

Manager / Supervisor: Enter Manager’s Name	Department: Enter Dept. Name

Manager: Initial the light duty tasks available in your area. When you have a task not listed on this form, please include it in the space provided. Provide a copy of this list to the injured employee and to their attending physician.

Treating Physician: Please initial those tasks you feel are within the current physical capacities of the employee you are treating. All tasks have been classified as sedentary or sedentary/light and can be used to accommodate most types of injuries. Physical Capacities of each task are available upon request, by email or fax.

Task Description	Available Tasks (MGR Initials)	Essential Skills & Required Body Parts	Physician Approval (Initials)
Additional Tasks

<CompanyName>

Notice of Transitional Work Assignment

Employee: Enter Employee’s Name Date of Injury: Enter Date of Injury

We have received information from your treating physician that you have been released to participate in our company’s Transitional Work Program. Through this program, we are able to provide you with a Transitional Work Assignment (TWA) while you recover from your injury.

The work activities we have chosen for you are within your physical restrictions, outlined in the attached work release. If you are assigned a task you consider to be beyond your physical capabilities, please let your manager, or <ResponsibleParty> know immediately. Since you are the best judge of your physical abilities, you must take responsibility to stay within the physical restrictions set by your treating physician.

The following is a detailed description of your TWA. Please review this information carefully before accepting or rejecting this notice of assignment. Failure to report to management or to return this notice, prior to the start date assigned below, will be viewed as a rejection and may affect your re-employment and rights to benefits.

Transitional Work Tasks
Start Date:
Shift:
Hours:
Location:
Report to:
Wage:
Review Date:

The TWA has been explained and it is agreed that the assignment will be reviewed as needed to assess the need to continue, modify or end the assignment.

I understand the terms of the TWA and __Accept __Reject the assignment offered on ___________.

Employee Signature: _________________________________ Date: __________________

Tasks Assigned By: ___________________________________ Date: __________________

Management Approval: ______________________________ Date: __________________