Colorado State University carries Workers’ Compensation insurance coverage for all its employees. This is required by law. Caring for an injured worker is important to us, and it is our intent to respond in a timely and responsive manner. Colorado State University and the Department of Environmental Health Services serve as liaison and employee advocate. We work with injured employees and employing departments to ensure proper medical care and/or assistance is provided, so employees can return to work.

Coverage

Colorado State University carries Workers' Compensation Insurance for all employees to assist them with expenses resulting from work-related injuries/illnesses. An employee is defined as an individual engaged under any appointment or contract for hire, expressed or implied. This includes faculty, staff, appointed officials, hourly personnel, student employees (including work-study) interns and graduate assistants performing work for which they are paid through the payroll. Insurance also covers students involved in nonremunerated internship, cooperative education and practicum programs. These non-remunerated students only are covered if assigned at non Colorado State University campuses or businesses. The insurance does not cover visitors, private contractors providing services for hire, or persons being paid by non-University sources even though working in a University facility or engaged in University projects.

EHS Responsibility

Environmental Health Services (EHS) is responsible for processing all claims initiated by university departments. The staff of EHS will assist with situations not covered in the following pages. EHS can be contacted by calling 491-6745.

Case handling for individual claims is the responsibility of Environmental Health Services.

Questions regarding specific claims procedures may be directed to Environmental Health Services at 491-6745.

Initial Written Reporting Requirements

A written report must be initiated immediately following an occupational injury or illness. This one page report included parts I and II which must be completed by the employee, and Part III which must be completed by the employee's supervisor. This report should be provided within 5 calendar days to Environmental Health Services.

1. Employee's Statement Part I & II.
   An employee who is injured or suffers an occupational disease as a result of job performance must file a written report with the employing department within four calendar days. The employee is required by law to complete and sign a written statement within four days of sustaining a work related injury or disease. Failure to do so can result in the loss of one day's benefits for each day's failure to report. The employee is to complete and sign Parts I and II of the "COLORADO STATE UNIVERSITY WORKERS' COMPENSATION INJURY REPORT" form. Supervisors should initiate report if injured employee is unable to do so because of the nature of the injury.
2. Supervisor's Section Part III.
   The employee's supervisor should review the employee's statement and then complete and sign Part III of the "COLORADO STATE UNIVERSITY WORKERS' COMPENSATION INJURY REPORT" form.

The employee's supervisor must review the information provided for accuracy, giving special attention to contributing conditions or circumstances which led to the accident/exposure. Environmental Health Services (EHS) should be contacted immediately if, in the department's opinion, the claim is questionable. If there are divergent observations among the injured/diseased employee, supervisor, other involved parties, or the department head concerning reported information, each may attach signed statements. The supervisor by signature, indicates concurrence with information contained in the report unless an addendum is attached.

Important Note

Employees and supervisors should keep in mind that this is a legal document and therefore must be complete, concise and be carefully reviewed.

One completed and signed copy of the "COLORADO STATE UNIVERSITY WORKERS' COMPENSATION INJURY REPORT" is to be forwarded to Environmental Health Services (EHS).

If the "COLORADO STATE UNIVERSITY WORKERS' COMPENSATION INJURY REPORT" is not received by EHS within 5 days following the date of injury or disease diagnosis, an explanation of reasons for late reporting must accompany the completed form. The employing department is subject to fines up to $500 a day for each day that the "COLORADO STATE UNIVERSITY WORKERS' COMPENSATION INJURY REPORT" is late.

Lost Time Memos

Whenever an employee loses time from work due to a work-related injury/disease, a memo from the employing department must be submitted to EHS stating the lost time of the employee. If the employee subsequently loses additional periods of time from work because of the same injury/illness, a new Lost Time Memo must be initiated and submitted by the employing department for each additional period.

Medical Treatment

In cases of job-related injury/disease, employees are required to obtain needed medical care either from Occupational Health Services at Poudre Valley Hospital, Concentra Medical Center, General Care Medical Clinic or WORKWELL Occupational Medicine. Exceptions will be made only in the following listed circumstance.

• An emergency in which an ambulance transports the patient to a hospital or an emergency attendant construes the degree of severity or urgency to require hospitalization.

Medical fees charged by an unauthorized provider will not be paid by the workers' compensation insurance carrier. An individual using an unauthorized provider will be responsible for the charges.

Rehabilitation Benefits

If, as a result of an occupational injury or illness an employee is permanently incapable of returning to former duties, the employee may be offered vocational rehabilitation training at the discretion of the insurance carrier.

Medical Costs

Employees normally should not pay for ambulance costs, physician's fees or prescribed therapies, drugs, laboratory tests and prostheses required as a result of job-related injury or compensable illness. The employee should inform the hospital, clinic, physician, or pharmacy that a Workers' Compensation claim has or will be filed and that the bills should be paid by the insurance carrier.

The insurance carrier will pay costs of accepted claims in accordance with fee schedules; the injured person is not obligated for any fees or interest in excess of those schedules. Bills received by the injured person should be forwarded to EHS for processing. If an employee does pay bills for a compensable case, detailed receipts should be sent to EHS for submission for refund.

Disability

The kinds of disabilities, a definition of each, and the applicable benefits are shown on the following table.

Costs Not Covered

Non-employment-related illnesses, injury, or health conditions are not covered by Workers' Compensation Insurance. Under most circumstances, there is NO COVERAGE for loss of clothing, personal property such as tools or books, or previously prescribed personal medical items such as eye glasses, dentures, hearing aids, or orthopedic devices. Injuries incurred en route to and from work are NOT covered. If travel is combination of University business and other purposes, benefits are paid only for injuries that occur during the University connected portion of the trip.

Reduction in Benefits

Employees may lose up to 50% of their compensation benefits and be denied injury leave, for which they would otherwise be eligible, when the injury/illness was caused by:

• Failure to use available safety devices.
• Intoxication.
• Failure to obey safety rules.
• Willful misconduct.
• Willful self-exposure.

An employee may lose one day of injury leave and/or one day's compensation for each day of late reporting.

Response of the Insurance Carrier to Claims and Employee Options

The insurance carrier may respond to an injury/illness claim in one of several ways.

• It may approve the claim for compensation.
• It may approve the claim for compensation but with a reduction in benefits (see above).
• It may delay action pending further medical evidence or other investigation of the claim.
• It may deny liability.
• Where there is the possible liability of a third party, it may delay action until the claimant chooses a course of action.
• It may call for a hearing before a Division of Labor referee.

An employee who does not feel that the response of the insurance carrier is correct or adequate may file for a review of the case.

Disabilities

Kind of Disablity	Defined	Amounts
TEMPORARY TOTAL to regular Faculty, Administrative Professional, or State Classified Personnel.	Total disability of more than 3 days.	Injury leave at full pay for up to 90 work days, then 2/3 of employee's weekly wage but not to exceed 80% of the State's Average Weekly Wage (SAWW).
PERMANENT TOTAL to regular Faculty, Administrative Professional, or State Classified Personnel.	Loss of both hands, or both arms or both legs, or both eyes, or any 2 thereof, or any total loss of earning capacity.	Injury leave at full pay for up to 90 work days, then 2/3 of employee's average weekly wage not to exceed the weekly maximum of the SAWW to continue until death of the injured person.
TEMPORARY TOTAL to hourly employees or work-study students.	Total disability of more than 3 days.	Payment by insurance carrier directly to employees at 2/3 of employee's average weekly wage not to exceed 80% of the SAWW. If disability lasts more than 2 weeks, compensation is paid beginning at first full lost work day.
PERMANENT TOTAL to hourly employees or work-study students.	Loss of both hands, or both arms, or both legs, or both eyes, or any 2 thereof, or any total loss of earning capacity.	Payment by insurance carrier directly to employee at 2/3 of employee's average weekly wage not to exceed the weekly maximum benefits specified for causing temporary total disability... to continue until death of the injured person.
TEMPORARY PARTIAL	Partial disabled, but able to resume work in a different capacity or work on a part-time basis at a reduce rate.	2/3 of the impairment of employee's earning capacity not to exceed a maximum of 80% of SAWW.
PERMANENT PARTIAL	Where full recovery is not possible from permanent disability. Scheduled monetary awards are given, dependent on type and extent of permanent disability.	This award is in addition and follows permanent partial disability payments which may be made.
Note: In cases involving injury leave, departments provide full pay of up to 90 work days for faculty, administrative professional and State Classified employees(not including holidays). INJURY LEAVE SHALL CEASE WHEN THE EMPLOYEE REACHES MAXIMUM MEDICAL IMPROVEMENT (MMI), OR RETURNS TO WORK OR IS ABLE TO RETURN TO WORK. EHS will receive and deposit in employing department's account, disability payments made to the University on behalf of injured employee by the insurance carrier while employee is on injury leave. This in accordance with C.R.S. 8-42-124 as amended. In addition, the insurance carrier provides up to $2,000 to compensate for visible disfigurement, up to $7,000 for burial expenses, and death benefits as set by statute.

Instructions For Preparation of Colorado State University Workers' Compensation Injury Report

1. Forward report to Environmental Health Services (EHS). EHS reviews and processes report prior to submission to insurance carrier. Use "N/A" for items not applicable and "none" for items with negative replies.
2. Late reports initiated 5 days or longer following the date of injury or disease diagnosis must be accompanied by the department's reasons for late report in writing.
3. The report should be reviewed by the supervisor and employee for validity and accuracy prior to signing. It may be appropriate to place the employee on injury leave, or to initiate some other personnel action at this time. The incident itself should also be reviewed to determine actions necessary to prevent similar occurrences.
4. Instructions For Preparation of Colorado State University Workers' Compensation Injury Report.
   Reports should be completed and forwarded on all occupational injuries and diseases reported by employees, even if the validity of a claim is doubtful. When there is doubt, the department, after reviewing the case, should forward a letter with the report identifying the circumstances determined by investigation. This letter should start with a paragraph similar to the following:

   "I am filing this claim in compliance with the Workers' Compensation law at the request of the employee who alleges he/she was injured/diseased in an accident/exposure arising out of or in the course of employment. I have no knowledge that such is the case and do not vouch for the truth of any statement made by the employee. Reported circumstances in Items 22 through 25 of "Colorado State University Workers' Compensation Injury Report" are as reported by the employee submitting the claim. I seriously doubt that he/she was injured (contacted the disease) as alleged and request an investigation of the circumstances and a hearing, if warranted."

Form Instructions

1-2 Use employee's name and social security number from personnel records.

4-5 Use current home phone and address.

9 Job title as shown on personnel records.

12 Marital status must show single, married, divorced, or widowed, as the case may be. A divorced or widowed person should not be shown as single.

14 Employee’s actual task (not job title) when injured/exposed.

18 Be sure wages are shown in correct space.

18(a) Hourly wage is used for hourly employees only.
18(b) Use only weekly wage for salaried personnel. To determine weekly wage, for this purpose, multiply monthly wage by twelve(12) and divide by fifty-two(52).

30 Name of first doctor. Be sure to include complete mailing address.

32 Date employee completes Part I and Part II, not the date of injury.

38 If State Classified employee, then list leave balance as of the date of injury.

42 The death of an employee as a result of a work-related accident must be reported immediately to EHS.

44 If any of these questions are answered yes, please attach a concise explanation of the circumstances so that the case can be properly evaluated. If failure to obey safety rules is reported, the explanation should show an actual written rule known to the employee and enforced by the department was violated.

45-46 Use employee’s current work phone and employee's primary department to which assigned by Payroll.

47 Signature of employee's supervisor. Supervisor, by signature, indicates concurrence with information as contained in the report form unless an addendum is attached.

48 Date supervisor completes Part III, not the date of injury.