Fill and Sign the Ma Workmans Comp Affidavit Form

DRIVER QUALIFICATION PROCESS It is presumed that all LSUHSC-NO positions require employees to travel at least occasionally in the performance of their duties and therefore must complete the below qualification process, unless and until specifically exempted in writing by their Department Head. To drive either a State-owned vehicle (SOV) or personally-owned vehicle (POV) on official University business, employees must possess a valid and properly classed license and complete the three step qualification process detailed below. In the case of POV usage, the vehicle must have the state required auto insurance coverage and the employee must be authorized to drive the vehicle under that insurance coverage. Unless employed by the University, students shall not be Qualified to drive State-owned, rented or their personally-owned vehicles on official university business. Individuals not completing all steps of the process will be considered out of compliance with University regulations, their supervisors will be notified and they will not be allowed to receive travel reimbursements of any kind. 1. Complete an Approved Driver Safety Training Course (DST) Candidate(s) must successfully complete the on-line DST, hosted by the Office of Compliance Programs’ (OCP’s) web-based training Knowledge Delivery System (KDS), or attend an equivalent classroom course. Training will be assigned automatically when due and can be accessed at OCP’s website at https://intranet.lsuhsc.edu/ctms/kds/ComplianceTrainingOnLine (For assistance call (504) 568-2350). Employees who do not have network access should contact Kelly Guth at kguth@lsuhsc.edu to schedule driver safety training. 2. Submit a DA-2054 (Authorization & Driving History Form) New employees are required to complete an Authorization and Driving History Form at time of hire and upon change of state issuance, class of license and/or driving restriction changes. The DA-2054 contains a statement that employees must sign certifying that they have and will maintain State required minimum liability insurance coverage on the vehicle they will be driving on official business and, upon request, show proof thereof. Completed and signed DA-2054s should be sent to the Environmental Health & Safety (EH&S) Office, by email to safetytraining@lsuhsc.edu, fax (504) 568-5185 or mail to Attn: Angelique Smith. Revised 4/14/2014 3. Official Driving Record For Louisiana driver: EH&S will obtain employee’s Official Driving Record (ODR) from the Office of Motor Vehicles (OMV) to ensure that Office of Risk Management (ORM) requirements are met. Non-Louisiana drivers’ license: While EH&S has access to Louisiana state driving records, it has no access to records of out-of-state licensees. Accordingly, if you possess an Out-ofState Driver’s License, you are required to obtain a CERTIFIED copy of your Official Driving Record (ODR) and have it sent to LSUHSC EH&S at: LSUHSC EH&S Attn: Angelique Smith 450A South Claiborne Avenue, Room 212 New Orleans, LA 70112 In most states, obtaining a current ODR is a simple procedure accomplished via their home website. Department of Motor Vehicle contact information for all states can be found at: http://www.4dmv.com/df_reportnrecord_driving_records.php . Once EH&S receives your initial ODR, you and your supervisor will receive a Qualification email which is good for one year. To maintain qualification, you must have your ODR sent to EH&S annually, 45 days prior to the expiration of your Qualification email. After receipt and review by EH&S, you and your supervisor will receive a “Qualification” email that is good for another 12 months. If you have recently obtained a Louisiana Driver’s License, please contact Angelique Smith as soon as possible for instructions. asmit3@lsuhsc.edu Qualification Qualification approval will be based on the full completion of all three steps of the process as well as the results of the ODR checks in accordance with ORM requirements. Once all of the above requirements are met, email notification will be sent to both the employee and their supervisor as to whether they have been Qualified or Not Qualified (based on a negative driving record; see enclosures 1, 2 and 3). Employees who have not received a Qualification email should not assume they are Qualified to drive on official University business. Note that employees with out of state drivers’ licenses require a “Qualification” email annually. Employees with Louisiana drivers’ licenses only receive an initial Qualification email, which remains valid as long as their ODR remains clean of violations and they complete the driver safety course every three years. Revised 4/14/2014 Page 2 Reportable Violations Employees are required to immediately report any moving violation(s) or revocation of their driver’s license to their supervisor and EH&S (asmit3@lsuhsc.edu). Reporting applies whether on state or personal/private business, and whether in a state or personal vehicle. “Moving violations” (defined below) require the completion of remedial driver safety training within 90 days of the violation to maintain “Qualified” driver status. “High Risk” violations (defined below) will result in a minimum 12 month suspension of authorization to drive on official University business. The Environmental Health & Safety Department will notify the individual and their department head or designated official if they require remedial training or are considered “High Risk”. Use of Wireless Telecommunications Devices Personnel shall not use a wireless telecommunications device while driving in a state-owned, leased, or private vehicle that is being driven on state business. This includes writing, sending, or reading a text based communication and engaging in a call. Use of a wireless telecommunication device is permissible for passengers in such vehicles. Exceptions:  Report a traffic crash, medical emergency or serious road hazard.  Report a situation in which the person believes his personal safety is in jeopardy  Report or avert the perpetration or potential perpetration of a criminal act against the driver or another person  Engage in a call or write, send or read a text-based communication while the motor vehicle is lawfully parked. Vehicle Accident Reporting A vehicular accident is defined as “any incident in which the vehicle comes into contact with another vehicle, person, object, or animal that results in death, personal injury, or property damage, regardless of: who was injured, what was damaged or to what extent, where it occurred, or who was responsible.” In case of an accident while driving any vehicle on official state business, we are required to send documentation to the Louisiana Office of Risk Management within 48 hours of the accident. When a vehicular accident occurs: 1. Call the local Police to report the accident and obtain a police Traffic Accident Report when available. If the accident involves LSU property or occurred on LSU grounds, notify University Police at (504) 568-8999 or (504) 568-8270. 2. If any serious injury or death is involved, you must immediately notify your supervisor. Your supervisor will immediately notify the LSUHSC-NO Office of the Vice Chancellor for Finance at risk@lsuhsc.edu and make senior LSUHSC leadership aware of the situation. Revised 4/14/2014 Page 3 3. If an accident results in injury to the employee (or other LSUHSC-NO employees), the employee’s supervisor shall immediately notify the LSUHSC-NO Office of Human Resources Management (HRM) (Attn: Paulette Albera @ (504) 568-3916 or palber@lsuhsc.edu). In addition, within five calendar days of the injury (or sooner if possible), the supervisor shall also prepare an Employer Report of Injury/Illness http://www.lsuhsc.edu/no/Administration/hrm/Forms/e1.doc (DA 1973, also referred to as an E-1) and submit to the Office of Human Resource Management (Attn: Worker’s Compensation - Paulette Albera). For more information, see Worker’s Compensation http://www.lsuhsc.edu/no/administration/hrm/relations/wrkcomp.aspx. 4. Completion of the ORM DA 2000 or 3000 form is not required for vehicular accidents. However, even if there were no injuries, you must complete and submit a DA 2041 Form http://www.doa.louisiana.gov/orm/pdf/da_2041.pdf (State Vehicle Accident Report) within 48 hours (weekends included). a. Email a copy of the completed DA 2041 to the LA Office of Risk Management through its Transportation Claims Unit being managed by FARA at claimopening@fara.com. b. Send a copy of the completed DA 2041 to LSUHSC-NO Office of the Vice Chancellor for Finance by fax at (504) 617-6950 or by email at risk@lsuhsc.edu. c. Include a copy of the police report along with the DA 2041 submission. HOWEVER, if not immediately available, submit the DA 2041 without it, and follow-up later when received. Note: A copy of a blank DA 2041 should be maintained in vehicles used for official state business at all times. The form can be downloaded from the following ORM website: http://doa.louisiana.gov/orm/formsCR.htm Recurring Training Requirement To maintain Qualification to drive on official state business, employees must repeat the Drivers Safety Training Course every three years and will be automatically prompted to do so by KDS. ODRs are reviewed annually to ensure compliance with ORM requirements. Definitions: Moving Violation: A moving violation occurs whenever a vehicle is in motion. Examples of moving violations include: speeding, running a stop sign or red light, driving without a license, making a left turn from the right hand lane. High Risk Driver: Individuals having three or more convictions, guilty pleas and/or nolo contendere pleas for moving violations or individuals having a single conviction, guilty plea or nolo contendere plea for operating a vehicle while intoxicated, hit and run driving, vehicular negligent injury, reckless operation of vehicle or similar violation, within a one year period. Revised 4/14/2014 Page 4 State Vehicle: Any licensed vehicle owned, leased and/or rented by the State of Louisiana. State (University) Business: Any legal and lawful activity conducted/engaged in, by an employee or agent of the State of Louisiana (LSUHSC-NO), on behalf of and benefiting the state (University) in the course and scope of their duties. Non-Drivers If you do not have a driver’s license or will never drive on official state business, please have your Department Head send a Do Not Drive Statement (Enclosure 4) by email to have your name removed from the Driver Education (DRED) requirements. Direct email to: Kelly Guth Compliance Educator Office of Compliance Programs/LSUHSC-NO 433 Bolivar Street New Orleans, LA 70112 Suite 811 Email: kguth@lsuhsc.edu Revised 4/14/2014 Page 5 Enclosure 1 (Qualification Email for Employees with Louisiana Licenses) This memo is to inform you and your supervisor that your DA 2054 Authorization Form , qualifying you to drive on official LSUHSC business has been approved. This approval allows limited secondary insurance coverage under the State of Louisiana, Office of Risk Management (ORM) policy. Please note that permission must be granted by your supervisor prior to departure on any official LSUHSC business. Remember, to maintain Qualification, please report any future vehicle Moving Violation Citations to the LSUHSC Environmental Health and Safety Office as soon as possible. Also, in the event you are involved in an automobile accident while driving on University business, in addition to the normal steps you would ordinarily take in the event of any accident, you need to: o Email a copy of the DA 2041 to the LA Office of Risk Management through its Transportation Claims Unit being managed by FARA at claimopening@fara.com within 48 hours(including weekends) o Also, send a copy of the DA 2041 to LSUHSC-NO Office of Risk Management at FAX number (504) 617-6950 “or” email at risk@lsuhsc.edu. o Include a copy of the police report along with the DA 2041 submission. HOWEVER, if a copy of the police report is not immediately available, do not delay submission of the DA 2041. Send the form later under separate cover when it is received to the above addressees. o In the event of serious injury or death, notify your supervisor immediately. (It is strongly recommended that a blank copy of the DA 2041 form be maintained in the state or personally-owned vehicle at all times. Downloadable versions of the form are available at: http://doa.louisiana.gov/orm/formsCR.htm.) If you have any questions, please contact Angelique Smith, safetytraining@lsuhsc.edu or 5686585. Revised 4/14/2014 Page 6 Enclosure 2 (Qualification Email for Employees with Out of State Licenses) This memo is to inform you and your supervisor that your DA 2054 Authorization Form , qualifying you to drive on official LSUHSC business has been approved. You are Qualified to drive for the next 12 months. This approval allows limited secondary insurance coverage under the State of Louisiana, Office of Risk Management (ORM) policy. Please note that permission must be granted by your supervisor prior to departure on any official LSUHSC business. Remember, to maintain Qualification you must  Report any future vehicle Moving Violation Citations to the LSUHSC Environmental Health and Safety Office as soon as possible.  Have your Official Driving Record sent from your state’s Department of Motor Vehicles to LSUHSC Environmental Health and Safety at least 45 days prior to the expiration of this Qualification. You will then receive another Qualification email good for another year. Also, in the event you are involved in an automobile accident while driving on University business, in addition to the normal steps you would ordinarily take in the event of any accident, you need to: o Email a copy of the DA 2041 to the LA Office of Risk Management through its Transportation Claims Unit being managed by FARA at claimopening@fara.com within 48 hours(including weekends) o Also, send a copy of the DA 2041 to LSUHSC-NO Office of Risk Management at FAX number (504) 617-6950 “or” email at risk@lsuhsc.edu. o Include a copy of the police report along with the DA 2041 submission. HOWEVER, if a copy of the police report is not immediately available, do not delay submission of the DA 2041. Send the form later under separate cover when it is received to the above addressees. o In the event of serious injury or death, notify your supervisor immediately. (It is strongly recommended that a blank copy of the DA 2041 form be maintained in the state or personally-owned vehicle at all times. Downloadable versions of the form are available at: http://doa.louisiana.gov/orm/formsCR.htm.) If you have any questions, please contact Angelique Smith, safetytraining@lsuhsc.edu or 5686585. Revised 4/14/2014 Page 7 Enclosure 3 (Remedial Training Required) The LSUHSC-NO Environmental Health and Safety Department has directed that you be enrolled in Remedial Driver Safety Training in order to satisfy Office of Risk Management requirements. In order to maintain your authorization to drive on state business, please complete this training within the next 90 days. To comply, click on the link below: https://intranet.lsuhsc.edu/ctms/kds/ComplianceTrainingOnLine Logon by filling in the following fields: *Username: lsumc-master\your LSU logon ID *Password: your LSU login password If you have any questions or concerns regarding how to complete the training, please contact me. Thanks, Kelly Guth Compliance Educator Office of Compliance Programs 433 Bolivar, Suite 811 New Orleans, LA 70112 Revised 4/14/2014 Page 8 Enclosure 4 (Do Not Drive Statement) I hereby certify that (insert name) will not be driving on official state business during the course of his or her duties, and, I will not approve any travel for this individual that involves mileage reimbursement, car rental or gas purchase, and if anything changes, I will notify you so you can add this person back to the requirements. Department Head, Print Name Date Signature Date Revised 4/14/2014 Page 9