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Workers’ Compensation ProgramAverage weekly wage70 percent of 400 (.7 x 400) equals 400 280When do impairment benefits begin? An injured worker becomes eligible forimpairment income benefits the day after the worker reaches maximum medicalimprovement.Impairment income benefits end after the worker has received three weeks ofpayments for each percentage point of impairment rating.Example: if an injured worker has an impairment rating of six percent, the worker wouldreceive eighteen (18) weeks of impairment income benefits.3. Supplemental Income Benefits (SIBs): If you meet certain requirements, you may be eligiblefor Supplemental Income Benefits (SIBs). To get SIBs, you need to apply four times a year(every three months). If you are eligible, you will get SIBs every month.To get SIBS, you must: have an impairment rating of 15% or more; have not returned to work. Or, if you did, but are earning less than 80% of the averageweekly wage in your position because of your injury; show that you are looking for work; and not accept a lump sum payment for your injury.4. Lifetime Income Benefits: An injured worker may receive lifetime income benefits if theworker has an injury or illness that results in the loss of the hands, feet, or eyesight, or if theworker meets the conditions listed in the Texas Workers’ Compensation Act. Lifetime incomebenefits equal 75 percent of the worker’s average weekly wage, with a 3 percent increaseeach year.Example: if a worker’s average weekly wage was 400, lifetime income benefitswould be 300 a week:Average weekly wage75 percent of 400 (.75 x 400) equals 400 300Lifetime income benefits begin whenever a work-related injury or illness causes theworker to meet the conditions listed in the Texas Workers’ Compensation Act.A worker may receive lifetime income benefits for the rest of his or her life.3. Death and Burial Benefits: Death benefits replace a portion of lost family income for theeligible family members of workers killed on the job. Burial benefits pay some of the deceasedworker’s funeral expenses. A family member may receive death benefits if the family memberis the spouse, dependent child or grandchild, or another eligible family member of a workerkilled on the job. Except for the spouse and minor children, to receive death benefits, familymembers must have been dependent on the deceased worker. For more information aboutdeath benefits, contact the ORM at 832-813-6896.ORM-WC-2014-100; Rev 05012015; Rev 09152018Page 7 of 16

Workers’ Compensation ProgramIV. Claim Information1. Injured Employee: When an employee is injured, the most important thing to do is to securethe appropriate medical treatment. In an emergency, dial 911. In case of a work related injury or illness requiring non-emergency services (i.e., backpain, sprained ankle, etc.) follow the Claims Reporting Instructions. After the appropriate medical treatment has been secured, the claim is to be reported tothe ORM.2. Claims Reporting Instructions: LSC must report the following to its insurance carrier, TPS,within eight (8) days of the date: An employee misses more than one (1) day of work because of a work-related injury; An employer knows about an occupational disease or illness even if the employee has notmissed any work; or An employee dies because of a work-related injury or illness.3. Report a Claim to the ORM:Refer to the following Responsibilities of the Employee and Responsibilities of theDirect Supervisor.4.What are the responsibilities of the employee?1. Any LSC employee who suffers an accidental injury or occupational disease as a direct result of and2.3.4.5.6.7.in the course and scope of employment should immediately notify his/her direct supervisor.Failure to report the injury within 24 hours of the occurrence of the injury (or the manifestation ofthe occupational disease) may result in the denial of the claim.The employee must complete an Employee Statement of Injury, and email the completed form tohis/her Direct Supervisor within 24 hours of the occurrence of the injury (or the manifestation ofthe occupational disease).Employee should immediately contact his/her Human Resource Director for direction or guidanceregarding how LSC benefits, such as leave, FMLA, group health, disability and retirement, etc., areaffected by a workers’ compensation claim. Please refer to HR Benefits.The employee must notify the ORM of any change in income regardless of whether the incomeincreased or decreased. If the employee starts working after a period, or has been made a bona fideoffer of employment, he/she must notify the ORM, even if employment or the offer is not withinthe LSC.If you miss work due to a work related injury, you must keep the LSC informed of your work statusby providing a DWC073, Work Status Report, to your Direct Supervisor and/or the ORM aftereach doctor visit. The treating doctor’s office must provide the report to you. A DWC073, isrequired after the initial examination and if you experience a change in work status, a substantialchange in activity restrictions, or as requested by the LSC.When your treating doctor releases you to return to work, you must report to work at thebeginning of your next regularly scheduled shift. The DWC073, report from your doctorindicating a return to work date or any work-related limitations must be given to your DirectSupervisor and the ORM before you return. If you are released to return to work withrestrictions, you must work with your Direct Supervisor and the ORM to comply with anyrestrictions the physician has indicated on a work status report.If it is necessary for the employee to change treating doctors for treatment of a work-related injury,ORM-WC-2014-100; Rev 05012015; Rev 09152018Page 8 of 16

Workers’ Compensation Program8.9.10.11.the employee must complete a DWC053, Employee Request to Change Treating Doctor, andreceive written approval from TPS before making the change.It is the employee’s responsibility to keep their contact information updated within iStar and withthe ORM. If home address, work address, or contact phone number changes the employeeshould notify the Human Resources (HR) and the ORM.You must continue communicating with your Direct Supervisor and the ORM throughout anyperiod of disability unless physically unable to do so.Except in an emergency, if the employee receives medical care for a work related injury that is notby or at the direction of the treating doctor, payment of any charges associated with that care maybecome the responsibility of the employee.For more information, contact the ORM at 832-813-6896.5. What are the responsibilities of the administrators and/or supervisors with direct managerialauthority over an employee’s job duties?1. Assist the injured employee in obtaining first aid or medical care when work related accidents,injuries, or occupational illnesses occur.2. Gather all pertinent information regarding the job related injury and report it to the ORM. This willinclude witness statements, if circumstances warrant.3. Provide the employee with a completed WC Initial Examination Authorization prior to medicaltreatment. If unable to provide the WC Initial Examination Authorization to the employee, priorto medical treatment, and the employee uses their health care insurance for a work related injurycontact the ORM immediately. The employee must contact their health insurance carrier and advisethe carrier their injury is work related as health insurance carriers will only communicate withthe member employee. (Refer to HIPPA)4. Provide the employee with a completed PMOA Workers' Compensation First Prescription Fill CardVoucher.5. Maintain a detailed record of the work-related injury, even if the employee did not lose time fromwork as a result of the injury. Document all related information, such as witness accounts, possiblefraudulent behavior, and/or any concerns regarding the incident.6. Complete the DWC001, Employers' First Report of Injury or Illness, if the employee isinjured, if the injury is an occupational disease, or if the injury resulted in a work related death. TheDWC001 must be emailed or delivered to the ORM within twenty-four (24) hours after receivingnotice that the employee is injured or has contracted an occupational disease. In the event of criticalinjury or death, immediate telephone notification should be given to the ORM at 832.813.6896followed by the DWC001.7. Employee’s Direct Supervisor must complete a Supervisor’s Accident Investigation Form within24 hours of the occurrence of the injury (or the manifestation of the occupational disease), andsubmit to the ORM.8. ORM will submit a DWC006 Supplemental Report of Injury to the carrier, on behalf of theSupervisor, for each of the following:a. The injured worker returned to work in either a full or limited capacity;b. The injured worker is earning more or less than the pre-injury wage because of the injury;c. The injured worker returned, then later had additional lost time or reduced wages as a resultof the injury; ord. The injured worker resigned or was terminated from employment.9. If the injured employee misses, or is likely to miss, more than seven days of work due to the injurythe Direct Supervisor must advise the ORM. The ORM will request the DWC003, Employer'sWage Statement from Payroll and contract the appropriate SHRM to update employee records. TheDWC003 is required whenever the employing department knows (or should have known) anemployee will miss more than seven (7) consecutive or cumulative days following the injury date.This is called the waiting period and no weekly compensation payment is due for the time lost forthat period. However, if an employee is off work for more than 14 calendar days, the weekly/ORM-WC-2014-100; Rev 05012015; Rev 09152018Page 9 of 16

Workers’ Compensation Programmonthly compensation for the waiting period is paid retroactively. Instructions for completing theform are included with the DWC003 form.10. An employee who is injured on the job is not required to “formally” report the injury if his or hersupervisor (or anyone with supervisory responsibilities) has actual knowledge that the injury wassustained in the course and scope of employment. The supervisor is responsible for ensuring theinjury or exposure is reported.11. Provide the injured employee with a copy of the completed DWC001, the Injured Employee Rightsand Responsibilities (Spanish) and Ombudsman Program Notice (Spanish) under the TexasDepartment of Insurance, Division of Workers’ Compensation each time an incident is reported.V.Department Procedures for Reporting Work Related Injuries1. If the injury or exposure is an emergency, call 911 and, if possible, contact the LSC PublicSafety at 281-290-5911.2. If the injury is a non-emergency, contact the LSC Public Safety at 281-290-5911.3. Stay with the injured employee or return to the scene until help arrives.4. Do not try to move the person unless further danger exists.5. All work-related injuries or illnesses must be reported. Complete the DWC001,Employer's First Report of Injury or Illness, and forward the completed form to the ORMwithin 24 hours of the injury. This form is required whether or not there is lost time fromwork.6. If the injury/illness involves more than one day of lost time from work, please call the HRBenefits Team at 832-813-6767, for more information about FMLA and procedures tofollow.7. When the employee is medically released by the treating physician and he/she physicallyreturns to work, the DWC006, Supplemental Report of Injury must be completed within 24hours of the return to work date. Please coordinate with the ORM to ensure this isaccomplished.8. Forward all doctor’s bills and/or notes to TPS.9. An employee who is injured on the job is not required to “formally” report the injury if hisor her supervisor (or anyone with supervisory responsibilities) has actual knowledge thatthe injury was sustained in the course and scope of employment. The supervisor isresponsible for ensuring the injury or exposure is reported.10. Maintain a detailed record of the work-related injury, even if the employee did not losetime from work as a result of the injury. Document all related information, such as witnessaccounts, possible fraudulent behavior, and/or any concerns regarding the incident.11. Employers who fail to file the DWC001, Employer’s First Report of Injury or Illness, in atimely manner without good cause may result in administrative violations.12. Any unsafe condition which may have caused the injury should be corrected. If assistanceis necessary to accomplish the correction, call the ORM at 832-813-6896.13. If it is necessary for the employee to change treating doctors for treatment of a work-relatedinjury, the employee must complete a DWC053, Employee Request to Change TreatingDoctor, and receive written approval from TPS before making the change.14. The LSC ORM may, at some point while the employee’s claim is pending, exercise itsright to have the employee evaluated by a physician chosen by the TPS claims adjuster.Such an evaluation will be done to determine if the employee is disabled due to the injury.If asked to see a physician chosen by TPS, the employee will be given notice of theappointment at least ten days in advance.15. If the treating doctor has questions about the types of services he or she may perform,please contact TPS at 1-800-588-0013.ORM-WC-2014-100; Rev 05012015; Rev 09152018Page 10 of 16

Workers’ Compensation Program16. Except in an emergency, if the employee receives medical care for a work related injurythat is not by or at the direction of the treating doctor, payment of any charges associatedwith that care may become the responsibility of the employee.VI.Employee Procedures for Reporting Work Related Injuries1. Notify your supervisor immediately, no matter how minor the injury may seem. Ifnecessary, report unsafe working conditions to your supervisor or to the ORM. Your failureto report an injury within 24 hours of the incident may result in the denial of a claim.2. If you miss work due to a work related injury, you must keep the LSC informed of yourwork status by providing a DWC073, Work Status Report, to the ORM after each doctorvisit. The treating doctor’s office must provide the report to you. A DWC073 is requiredafter the initial examination and if you experience a change in work status or a substantialchange in activity restrictions, or as requested by the LSC.3. When your treating doctor releases you to return to work, you must report to work at thebeginning of your next regularly scheduled shift. The DWC073 report from your doctorindicating a return to work date or any work-related limitations must be given to the ORMbefore you return. If you are released to return to work with restrictions, you must workwith your supervisor and the ORM to comply with any restrictions the physician hasindicated on a work status report.4. You must continue communicating with your supervisor and the ORM throughout anyperiod of disability unless physically unable to do so.5. For more information, contact the ORM at 832-813-6896.VII.Lost-Time-Injuries Procedures1. Employee should immediately contact his/her Human Resource Director for direction orguidance regarding how LSC benefits, such as leave, FMLA, group health, disability andretirement, etc., are affected by a workers’ compensation claim. Please refer to HR Benefits.2. Upon recuperation of the insured employee a doctor's statement, DWC073, Work StatusReport must be presented to the ORM before the individual will be allowed to return towork. The statement should include dates of incapacitation, date released to return towork, limitations, and reason for confinement.3. When the injured employee is returning to an active status, the employing department shallimmediately contact the ORM and the campus HR Director.4. The ORM shall be notified immediately the day an injured employee returns to work inorder to discontinue the weekly Workers' Compensation payments.VIII.No Lost Time Injuries ProceduresWhen an employee is able to return to work on or before the next regularly scheduledworkday after the work related injury was sustained, it will be considered a no-lost-timeinjury and the employee will not lose any time or pay as the result of the injury. No chargewill be made to the employee's vacation or sick leave for the time lost as a result of the nolost-time injury. However, for follow-up doctor's appointments the employee is required touse sick leave, vacation or compensatory time. This also applies to an employee who hasreturned to work after a lost time injury/illness and follow-up doctor's visits are necessary.ORM-WC-2014-100; Rev 05012015; Rev 09152018Page 11 of 16

Workers’ Compensation ProgramIX.Payment of Benefits1. WCP income benefits will be paid weekly. The check will be mailed to the employee’shome address. Employees must notify the ORM when addresses change during a WCPleave of absence.2. Each check is issued with a pay period beginning and ending date. Checks cannot bereleased prior to the date and times listed above. Employees will be notified by mailregarding Holiday schedules. There are no exceptions to this policy.X.Exceptions: Texas Labor Code, Title 5, Chapter 406, Sec. 406.032:An insurance carrier is not liable for compensation if the injury:a) occurred while the employee was in a state of intoxication;b) was caused by the employee's willful attempt to injure himself or to unlawfully injure anotherperson;c) arose out of an act of a third person intended to injure the employee because of a personal reason andnot directed at the employee as an employee or because of the employment;d) arose out of voluntary participation in an off-duty recreational, social, or athletic activity that did notconstitute part of the employee's work-related duties, unless the activity is a reasonable expectancy ofor is expressly or impliedly required by the employment;e) arose out of an act of God, unless the employment exposes the employee to a greater risk of injuryfrom an act of God than ordinarily applies to the general public; orf) was caused by the employee's horseplay.XI.Nondiscrimination against Claimants1. The LSC shall n

Workers' Compensation Program ORM-WC-2014-100; Rev 05012015; Rev 09152018 Page 4 of 16 I. Introduction The Lone Star College System (LSC) Workers' Compensation Program (WCP), (See LSC Policy Manual, IV.E.5,Section Workers' Compensation Program), provides medical benefits and income indemnity for injuries and occupational illnesses that arise out of the course and scope of