Telephone: (808) 956-3100
Fax (808) 956-5022
The Research Corporation of the University of Hawaii
Human Resources Office
First issued: 06/27/2002
Revised: 09/25/2008, 08/26/2013
MEMORANDUM
TO:
RCUH Employee
FROM:
Nelson Sakamoto
Director of Human Resources
SUBJECT:
Guidelines If You Suffer a Work-Related Injury/Illness
If you have suffered a work-related injury or illness, you should read this memo and follow the guidelines
provided below:
Applicable RCUH Policies:
1. RCUH Policy 3.580 RCUH Workers’ Compensation Policy
2. RCUH Policy 3.930 RCUH Safety & Accident Prevention Policy.
Reporting Deadline of Any Work-Related Injury/Illness to Your Supervisor:
Any work-related injury/illness must be reported to your supervisor immediately after its occurrence.
The RCUH Supervisor’s Report of Industrial Injury & Accident Investigation Form (D-25) must be completed
by your supervisor, reviewed/signed by you (injured employee) and your supervisor. In addition, you will
need to sign the Employee/Claimant Consent Form (D-26). Both forms may be obtained via the RCUH
Home Page (www.rcuh.com).
Reporting Deadline for Your Supervisor’s Report to the RCUH:
Both the Supervisor’s Report of Industrial Injury Accident Investigation Form and the Employee/Claimant
Consent Form must be sent to the RCUH Human Resources Department immediately (i.e., within 24
hours of its occurrence). An explanation may be needed, if there are any delays in reporting the claim.
RCUH Responsibilities in Reviewing & Reporting Your Claim:
The RCUH Human Resources Department will review the Supervisor’s Report of Industrial Injury &
Accident Investigation Report. The RCUH Human Resources Department may request clarification and
may initially deny your claim until an investigation can be completed. The investigation is to ascertain
whether the injury is job related. The RCUH will report claim to our third-party administrator, First Insurance
Company of Hawaii (FICOH), First Risk Management Services (FiRMS Claims Services) as soon as we
receive your claim.
Third Party Administrator Responsibilities in Claims Administration:
The RCUH has contracted an insurance company to provide the organization with a comprehensive
workers’ compensation insurance policy. All claims for workers’ compensation made by an RCUH
employee will be administered through a third-party administrator (i.e., FiRMS Claims Services.). All issues
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John A. Burns Hall, 4 Floor Makai Wing, 1601 East West Road ● Honolulu, Hawaii 96848
An Equal Opportunity Employer
relating to your claim will be handled by an assigned Claims Adjuster. You will receive a letter in the mail
and/or a phone call from this Adjuster. The Adjuster will interact with you and your physician on all matters
concerning your workers’ compensation claim. You are to contact this Claims Adjuster for any questions
you have about your case. Cooperation is important.
FiRMS Claims Services will complete a WC-1 Employer’s Report of Industrial Injury form. This form will be
sent to the State of Hawaii Department of Labor & Industrial Relations Disability Compensation Division
within seven (7) working days from the date of injury. Therefore, it is very important that your accident is
reported promptly to your supervisor so it can be delivered to FiRMS Claims Services in a timely manner.
Workers’ Compensation Benefits:
All benefits are specified in Chapter 386, of the Hawaii Revised Statutes (Hawaii Workers’ Compensation
Law, or related laws). In most cases, if your claim for benefits is accepted, these benefits will cover all
medical expenses and lost work time due to disability from this work related injury.
Lost Time from Work:
All “lost time” due to the work-related injury must be certified by the employee’s primary treating physician.
The RCUH does not allow “back dated” (i.e., after the fact) medical certifications. Therefore, an employee
must see his/her primary treating physician and be certified as disabled from work from the first day of
his/her disability.
For wage loss replacement, there is a mandatory 3-day waiting period. On the fourth day of disability, the
employee will commence receiving 66 2/3% of his/her Average Weekly Wage (AWW). Our respective
insurance carriers are responsible for sending you your Temporary Total Disability (TTD) checks. This
AWW will remain the same (i.e., based on the AWW value at the date of injury) throughout the duration of
the claim. The employee is allowed to use sick leave during the first 3 days of the waiting period or if the
employee has no sick leave or vacation, he/she will be placed on a leave without pay status. All claims for
workers’ compensation benefits must adhere to the provisions of Chapter 386, H.R.S. (Hawaii Workers’
Compensation Law).
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John A. Burns Hall, 4 Floor Makai Wing, 1601 East West Road ● Honolulu, Hawaii 96848
An Equal Opportunity Employer
Questions & Answers:
1. What information do you need to provide to the doctor?
You will need to explain to the doctor’s office that you are an employee of the RESEARCH
CORPORATION OF THE UNIVERSITY OF HAWAII (RCUH). If they have any questions, have the
doctor’s office contact the RCUH Human Resources Department at (808) 956-3100. Please make
sure you identify RCUH as your employer to avoid bills or reports from being sent to the wrong
office.
You should inform the physician “where you are injured”, “when the injury occurred”, and “what
were you doing when the injury occurred”.
2. Where does the doctor’s office send the bills and reports?
All billings and medical reports relating to your work injury should be sent to:
First Insurance Company of Hawaii
FiRMS Claims Services
P.O. Box 2866
Honolulu, Hawaii 96803
(808) 527-7711 (main line)
(808) 545-3120 (fax)
Your doctor should call FiRMS Claims Services if they have any questions relating to their claims
processing.
3. What happens if my claim is denied?
The RCUH will instruct the Claims Adjusters to review your claim for worker’s compensation
benefits to determine if it is “job related”. Any lost time (related to the injury) during the “denial
investigation” period, should be charged as “Sick Leave” (if available) or Leave Without Pay (if you
are not eligible for sick leave). The Insurance Company and/or Claims Adjusters may request to
review all relevant medical information from your physician and/or send you to an independent
medical review. A determination will be made approximately thirty (30) days from the report of
injury. You will be notified by the Claims Adjuster of this determination.
The Claims Adjustor will inform you if your claim is determined to be “compensable” (i.e., you are
eligible for workers’ compensation benefits). Any sick leave payments will be adjusted for TTD
benefits. Upon receipt of the TTD payment, the RCUH Human Resources Department will adjust
your sick leave records (i.e., restore the sick leave applicable to the TTD payment/period).
4. Who do I inform about any changes in my work status, schedule, etc.?
You need to inform both your Supervisor and the Claims Adjuster. All medical reports should be
sent to the Claims Adjuster (i.e., FiRMS Claims Services, Inc.). Any changes in your work schedule
due to disabilities, treatments, etc. must be coordinated with your Supervisor and the Claims
Adjuster. You and your doctor should try to schedule all appointments during your “off hours”.
Contact your Claims Adjuster if you and/or your physician cannot schedule the appointments,
treatment, or therapy outside of your work schedule. Your Claims Adjuster and your Supervisor
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John A. Burns Hall, 4 Floor Makai Wing, 1601 East West Road ● Honolulu, Hawaii 96848
An Equal Opportunity Employer
will need this information.
5. Who needs to know about my condition?
(1) Your Supervisor/PI: You should provide your supervisor with information on how your injury
will affect doing your job. Your condition may affect your ability to return to work, your work
schedule, and/or your ability to perform your job.
(2) Your WC Claims Adjuster: You must provide your adjuster with any/all medical reports from
your doctor.
6. What do I do if I disagree with any action taken by the Claims Adjuster?
You are to contact Mary Ku, WC Supervisor and/or Julie Brewer, Adjuster of FiRMS Claims
Service.
7. What do I do if I disagree with any action taken by my Supervisor relating to my claim?
You are to contact the RCUH Human Resources Department and ask to speak to the Director of
Human Resources at (808) 956-3100.
th
John A. Burns Hall, 4 Floor Makai Wing, 1601 East West Road ● Honolulu, Hawaii 96848
An Equal Opportunity Employer
3.930 RCUH Safety & Accident Prevention Program
Form BEN-3 (Rev. 7/02, 2/04, 5/04, 3/05, 9/09, 10/09, 4/10, 6/12)
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
SUPERVISOR'S REPORT OF INDUSTRIAL INJURY
Fax (808) 956-5022 or email (rcuhhr@rcuh.com) to RCUH HR within 24 hours of Injury/Illness/Accident
Original form should be sent to RCUH HR, 1601 East-West Road, Burns Hall, Honolulu, HI 96848
(Part A and Part B MUST be completed)
1. EMPLOYEE'S NAME (Last, First, MI)
4. EMPLOYEE’S RCUH ID#
7. DATE OF INJURY
2. PROJECT NAME
3. CLASSIFICATION:
Regular
Student
Temporary
Volunteer
5. EMPLOYEE'S ADDRESS(No., Street, City, State, Zip Code)
8. DATE INJURY REPORTED TO
SUPERVISOR
6. JOB TITLE
9. TIME WORKSHIFT BEGAN
__________A.M./P.M.
11. ACCIDENT LOCATION & ADDRESS (Ex., Loading dock north end; 2432 N. St. Hilo, HI)
10. TIME OF INJURY
________A.M./P.M
12. WITNESS(ES) NAME (Last, First)
13. HOW DID THIS ACCIDENT OCCUR? (Please describe fully the events that resulted in injury or occupational disease. Tell what happened.)
14. WHAT WAS THE EMPLOYEE DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material the employee was
using.)
15. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE? (e.g. the machine employee struck against or struck him,
the vapor or poison inhaled or swallowed, etc.)
16. EMERGENCY CARE AND PATIENT STATUS
First Aid Only (i.e., employee was not referred to hospital or doctor)
Referred to hospital/doctor, current status unknown
Treatment at hospital/doctor (complete name/address of physician below)
17. EMPLOYEE STATUS
Was employee paid in full for day of accident?
Has employee returned to work?
Will employee lose time from work?
Yes or
Yes or
Yes or
No If “Yes”, enter date returned:
No If “Yes”, please explain:
Indicate any other information about the employee’s status:
Form BEN-3
Page 1 of 3
No
3.930 RCUH Safety & Accident Prevention Program
Form BEN-3 (Rev. 7/02, 2/04, 5/04, 3/05, 9/09, 10/09, 4/10, 6/12)
18. IDENTIFY SPECIFIC BODY PART(S) INJURED.
***Describe the injury/illness
***Mark (“X”) the injured body part(s) on diagram below and have employee initial by the injured body part(s).
FRONT
RIGHT
BACK
LEFT
LEFT
RIGHT
STATEMENT OF CERTIFICATION (Any falsification of this report may result in disciplinary action)
_______________________________ _____________ ______________________________
19. Supervisor’s Signature
20. Date
21. Employee’s Signature
_____________________________________
19a. Print Name/Phone Number/Fax/Email of Supervisor
Form BEN-3
Page 2 of 3
________________
22. Date
_____________________________________________________
21a. Print Name/Work & Home Phone Numbers/Email of Employee
3.930 RCUH Safety & Accident Prevention Program
Form BEN-3 (Rev. 7/02, 2/04, 5/04, 3/05, 9/09, 10/09, 4/10, 6/12)
PART B:
ACCIDENT INVESTIGATION:
1.
What type of safety equipment and/or procedure was involved in this work process? Did the employee use the
equipment or follow the procedure?
2.
What kind of actions do you plan to implement to prevent this type of accident from recurring?
3.
Have you instructed the employee on how to avoid the recurrence?
4.
Was a Safety Rule violated? If so, has the employee been disciplined for violating the safety rule?
Additional comments relating to Accident Prevention and/or investigation:
_________________________________________
Supervisor’s Signature
_____________________________________________________
Project Safety Coordinator’s Signature
________________________________________________________________
Print Name/Phone Number/Fax/Email of Safety Coordinator
REVIEWED BY PRINCIPAL INVESTIGATOR:
__________________________________________
Principal Investigator’s Signature
_______________________________________________________________
Print Name/Phone Number/Fax/Email of Principal Investigator
REMINDERS:
1. If this is more than a “first aid” type injury or if the employee will lose time from work, the Employee must be seen by a Physician.
2. Complete and Attach EMPLOYEE/CLAIMANT CONSENT FORM (D-26) to this report and send both in to the RCUH Director of Human Resources
immediately. Fax to 808/956-5022 AND mail original forms to RCUH HR, 1601 East-West Road, Burns Hall, Honolulu, HI 96848.
3. Scan and email photo(s) of the injury(ies), location/work environment, object that may have caused the injury, etc. to rcuhhr@rcuh.com.
4. Refer to RCUH 3.580 Workers’ Compensation and 3.930 Safety and Accident Prevention Program policies for more information.
5. Provide the Employee with the “Guidelines to Employee Memo” located on the WC policy.
Form BEN-3
Page 3 of 3
3.930 RCUH Safety & Accident Prevention Program
Attachment 2
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
EMPLOYEE/CLAIMANT CONSENT FORM
TO:
RCUH Director of Human Resources
I,
, hereby authorize my physician, hospital,
clinic, insurance company or other institution or person to permit the bearer of this consent
form or the Research Corporation of the University of Hawaii (RCUH), or its authorized
representatives, claims adjusters, and insurance representatives to receive clarification on
any medical information provided to by a certified/authorized medical practitioner, view,
copy or be furnished copies of any and all medical information, including x-rays, relating to
(check appropriate box):
Processing/Administration of my industrial accident and related workers
compensation benefits (in addition, this authorization allows release and access to
treatments rendered to me for my injury/illness; includes results of psychiatric/
psychological and substance abuse testing, and as applicable prior medical history
related to this injury/illness).
Post offer physical examination
Periodic physical examination
Medical certification required by RCUH policy (Sick Leave, LTDI, etc.)
I understand that this authorization is for a specific time period (not to exceed the
time necessary to process the action checked above) and may be revoked at anytime in
writing. I understand this authorization is specifically for the processing of the purpose
stated above.
I agree that a copy of this authorization bears the same authority as the original.
Signature of Employee/Claimant
cc:
Date
Physician(s)________________________________
Effective December 16, 1993 (Revised September 2002)
RCUH Form D-26
