You are on page 1of 16

WORKERS COMPENSATION

INSTRUCTION BOOKLET

SEMINOLE COUNTY PUBLIC SCHOOLS


RISK MANAGEMENT & EMPLOYEE
BENEFITS DEPARTMENT
www.scps.k12.fl.us
(Risk Management Department)

2014-2015

TABLE OF CONTENTS

Page

Title of Forms

Table of Contents

Workers Compensation Important Numbers

3-5

Instructions for Processing a Workers Compensation


Report of Injury or Illness

6-7

First Report of Injury or Illness


(Available electronically upon request)

Notification Form

Medical Providers List

10

Medical Report for Treatment Form

11

PMOA Workers Compensation Prescription Information Form

12

Participating Pharmacies List

13

Choice Form

14

Temporary Staffing Employment Agencies

15

Important Reminders

(Revised June 2014)

WORKERS COMPENSATION IMPORTANT NUMBERS


Florida School Boards Insurance Trust (FSBIT)
Post Office Box 10709
Tallahassee, Florida 32302-2709
Main Number: (850) 414-0818 x 327
Toll Free Number: (800) 790-2118 x 327
Fax: 850-414-0893
Karey Edwards (WC Claims)(Last Names A-O)
kedwards@fsbit.net, Extension 315
Krista Casey (WC Claims Only) (Last Names P-Z)
kcasey@fsbit.net, Extension 318
Rhonda Brock, RN (Nurse Case Manager)
rbrock@fsbit.net, Extension 312
Todd Scott (Property & Casualty Adjuster)
tscott@fsbit.net, Extension 307
Linda Quick (C.F.O/Coordinator of Business Services)
lquick@fsbit.net, Extension 305
James D. Barnidge (Claims Manager/Coordinator of Loss Prevention Services)
jbarnidge@fsbit.net, Extension 306
David Stephens (Director of Risk Management)
dstephens@fsbit.net, Extension 303

Seminole County School Board


Risk Management Department
David R. Apfelbaum, Director
(407) 320-0208
Dawn Lobkovich, Executive Secretary
(407) 320-0242
Fax: (407) 320-0411

(Revised June 2014)

INSTRUCTIONS FOR PROCESSING A


WORKERS COMPENSATION REPORT OF INJURY OR ILLNESS
FOR SEMINOLE COUNTY PUBLIC SCHOOLS
When an employee reports that he/she has suffered a work related injury, the
employee must complete a First Report of Injury or Illness form, Form DFS-F2-DWC-1
(this includes employees working through a temporary staffing employment agency, see
page 14). If the employee cannot sign or fill out the form, the workers compensation
contact is to complete the form to the extent of known information.
1.

The First Report of Injury or Illness form must be completed using the electronic
Word template. The employee has to provide the information necessary to complete
the electronic form. The employee must designate the date on which the injury
occurred and/or the claimed condition or illness manifested. The cost center workers
compensation contact should not assist the employee in determining what date
is to be used. The workers compensation contacts must print the electronic form and
have the employee review and sign the form.
2.

3.
The workers compensation contact must keep the original signed form in the
injured employees workers compensation file at the cost center.
Again, if the
employee cannot sign the First Report of Injury or Illness form, the signature box,
located on the bottom of the form is to be marked not available at this time. An
amended form is to be completed as soon as the injured employee is able to sign.
A copy of the form should be given to the cost center supervisor, as well as any medical
work status information received by a doctor.
4.
The completed First Report of Injury or Illness form for employees should then
be emailed to Dawn Lobkovich at dawn_lobkovich@scps.k12.fl.us in the Risk
Management Department within one business day. The email subject line should read:
First Report of Injury and illness or simply FROI. Risk Management will need a copy
of the signed First Report of Injury or Illness form with the employees signature
for the Risk Management file, which can be sent via courier or fax to (407) 3200411 or ext 50411.
5.
Temporary Staffing Employees:
Any person employed by a temporary
staffing agency who has been assigned to work at a SCSB facility and who has suffered
an injury in the course of performing his or her employment duties will need to be
referred to the temporary staffing agencys workers compensation contact (see page
14). (Give the injured temporary worker a copy of page 14 and document in writing that
the temporary worker has been given the reporting information).
Any person who is not employed by SCSB but who is injured while at an SCSB facility
should be referred to that persons employers workers compensation contact.

(Revised June 2014)

HOWEVER, IT IS IMPORTANT THAT A SCHOOL ADMINISTRATOR


INVESTIGATE ANY CLAIMED INJURIES AND COMPLETES AN INJURY
REPORT FORM FOR THE INCIDENT WHETHER OR NOT TREATMENT IS
REQUESTED (SCSB Form No.447).
6.
Medical Treatment Claims: Once the employee has requested to seek medical
treatment, in addition to completing the First Report of Injury or Illness form, the
following forms should be filled out. The forms listed below are not to be given to
employees hired through a temporary employment agency, see page 14:

Notification Form (Page 8)


Medical Report for Treatment Form (Page 10)
PMOA Workers Compensation Prescription Information Form (Page 11)

The following forms are to be given to the regular employees to take along to the doctor
for treatment. Again, the forms listed below are not to be given to employees hired
through a temporary employment agency, see page 14:

Medical Report for Treatment Form (Page 10)


PMOA Workers Compensation Prescription Information Form (Page 11)

(Please note: that the PMOA Workers Compensation Prescription Information


included is temporary. A prescription card will be mailed to the injured
employees home address.)
The following forms are to be given to the employee for their information:

Medical Provider List (Page 9)

The workers compensation contact should then direct the employee to the most
convenient Centra Care or Care Spot Medical Facility, and the workers compensation
contact should keep a copy of all forms given to the injured employee for the
employees workers compensation file.
7.
Report Only Claims: The workers compensation contacts are to give the injured
employee the following documents only if they are not seeking medical attention, in
addition to the First Report of Injury or Illness form:

Notification Form (Page 8)

Please note that if at a later date the injured employee wants to seek medical
treatment, update the First Report of Injury or Illness form to show that the injured
employee wishes to seek medical treatment and refer back to steps #4 and #6. When
there is a delay, the adjuster should make the determination on referral for care unless
it is a true emergency (if care is delayed, it shouldnt be an emergency).

(Revised June 2014)

8.
The workers compensation contact does not need to obtain a signed Choice
Form (Page 13), until the employee is taken off duty by a doctor. Then if
the employee wants to charge the difference between workers compensation
pay and his/her full salary, the employee may choose to use part of his/her sick
leave or vacation leave. The workers compensation contact is to send the original
signed Choice Form (Page 13) to the cost centers payroll specialist in the Human
Resources Department and place a copy in the injured employees file at the cost
center. Do not send a copy of this form to Risk Management.
9.
The first ten (10) days of an injured employees absence from work due to
doctors orders (must be verified by a signed notice from the authorized workers
compensation doctor) is to be reported as In-Line-of-Duty-Leave (payroll code:
INDLV). Workers compensation will take effect for payment of wage benefits for the
employee starting on the 11th day. The 11th day, and thereafter, should be reported
under workers compensation payroll code: WKCOMP. Under all circumstances, when
an injured worker has been written out of work by the doctor, the Risk Management
Department must be notified immediately.
If the employee is not out for the full ten (10) days, the unused days may be
used if the employee requires additional time off (due to doctors written orders) for
additional treatment, etc. The maximum that will be paid is ten (10) days per year.
Please note that only unused days relating to a specific injury will be carried forward to
subsequent years. The workers compensation contacts are to report all time missed by
the injured employee to Risk Management Department on a weekly basis via email.
10.
The workers compensation contacts are to report any change in status, such as,
if the injured employee is placed on light duty, modified duty, etc., to Florida School
Boards Insurance Trust (FSBIT) via fax, e-mail or telephone contact. The Risk
Management Department must be notified as well.
11.
Please call Florida School Boards Insurance Trust (FSBIT), if you have any
workers compensation questions. The School Board has contracted with Florida
School Boards Insurance Trust to process all workers compensation claims. Please
advise employees to call FSBIT with any questions. Employees who call Risk
Management will be redirected to Florida School Boards Insurance Trust.

(Revised June 2014)

RECEIVED BY
CLAIMS-HANDLING ENTITY

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

FIRST REPORT OF INJURY OR ILLNESS


FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)

SOCIAL SECURITY NUMBER

HOME ADDRESS

EMPLOYEES DESCRIPTION OF ACCIDENT (include Cause of Injury)

DATE OF ACCIDENT

TIME OF ACCIDENT

(Month-Day-Year)

AM

PM

,
TELEPHONE

Area Code

Number

OCCUPATION

INJURY/ILLNESS THAT OCCURRED

DATE OF BIRTH

PART OF BODY AFFECTED

SEX

F
EMPLOYER INFORMATION

EMPLOYER/COMPANY

FEDERAL I.D. NUMBER (FEIN)

Seminole County School Board


400 East Lake Mary Boulevard
Sanford, FL 32773-7127
TELEPHONE

Area Code

DATE FIRST REPORTED (Month-Day-Year)

596000855
NATURE OF BUSINESS

POLICY/MEMBER NUMBER

Municipality

Number

Self-Insured

DATE EMPLOYED

PAID FOR DATE OF INJURY

LAST DAY EMPLOYEE WORKED

WILL YOU CONTINUE TO PAY WAGES


INSTEAD OF
WORKERS COMP?
YES

(407) 320-0242 or (407) 320-0208

YES

EMPLOYERS LOCATION ADDRESS (if different)

RETURNED TO WORK?
IF YES, GIVE DATE

YES

NO

LAST DAY WAGES WILL BE PAID INSTEAD OF


WORKERS COMP?

NO

Location #:
PLACE OF ACCIDENT (Street, City, State, Zip)

DATE OF DEATH (If applicable)

RATE OF PAY
PER

AGREE WITH DESCRIPTION OF ACCIDENT?

YES

COUNTY:

HR
DAY

Number of hours per day


Number of hours per week

NO

Number of days per week

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program,
files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section
440.105(7), F.S.

I have reviewed, understand and acknowledge the above statement.

NAME, ADDRESS AND


TELEPHONE
OF PHYSICIAN OR HOSPITAL

__________________________________________________________ _____________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
______________________________________________________________ ________________________________
EMPLOYER SIGNATURE/ Phone Number
DATE

CLAIMS-HANDLING ENTITY INFORMATION


1(a)

Denied Case DWC-12, Notice of Denial Attached

1(b)

Indemnity Only Denied Case DWC-12, Notice Of Denial Attached

2. Medical Only which became Lost Time Case

3.

Lost Time Case 1st day of disability

(Complete all required information in #3)

Employees 8th Day Of Disability


Entitys Knowledge of 8th Day of Disability
Full Salary in lieu of comp?

Date First Payment Mailed


T.T.

AWW

T.T.- 80%

T.P.

I.B.

YES Full Salary End Date

Comp Rate
P.T.

DEATH

Penalty Amount Paid in 1st Payment

SETTLEMENT ONLY

Interest Amount Paid in 1st Payment

REMARKS:

INSURER NAME

INSURER CODE #

EMPLOYEES CLASS CODE

EMPLOYERS NAICS CODE

Florida School Boards Insurance Trust


P. O. Box 10709
Tallahassee, FL 32302-2709
850-414-0021

9432
SERVICE CO/ TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

6214
Form DFS-F2-DWC-1 (03/2009) Rule 69L-3.025, F.A.C.

(Revised June 2014)

CLAIMS HANDLING ENTITY NAME, ADDRESS & TELEPHONE

WK
MO

DWC-1 Purpose and Use Statement


The collection of the social security number on this form is
specifically authorized by Section 440.185(2), Florida Statutes.
The social security number will be used as a unique identifier in
Division of Workers' Compensation database systems for
individuals who have claimed benefits under Chapter 440, Florida
Statutes. It will also be used to identify information and
documents in those database systems regarding individuals who
have claimed benefits under Chapter 440, Florida Statutes, for
internal agency tracking purposes and for purposes of responding
to both public records requests and subpoenas that require
production of specified documents. The social security number
may also be used for any other purpose specifically required or
authorized by state or federal law.

(Added 05/2011)

(Revised June 2014)

NOTIFICATION FORM
FOR SEMINOLE COUNTY SCHOOL BOARD

PRINT EMPLOYEES NAME: ________________________________________


DATE OF INJURY:
This is to advise you that it is your responsibility to notify your supervisor and the
person who handles workers compensation claims at your school/division of
your duty status and/or duty limitations. This notification should normally be the
same day as your doctor/hospital visit. If this is not possible, then notification
should be made to the above mentioned persons on the next regular duty day.
When you return to duty, you are to turn in the physicians duty slip to your
workers compensation processor. Make sure you have a duty slip for each visit
with the physician. It is imperative that your supervisor know what, if any, duty
limitations the physician has prescribed. Further, be advised that once released
to return to duty by your physician you are to report as directed. FAILURE TO
REPORT FOR DUTY OR PROPERLY REPORT YOUR ABSENCE PURSUANT TO
BOARD POLICY AND/OR NEGOTIATED CONTRACT LANGUAGE WILL RESULT IN
YOU BEING ABSENT WITHOUT APPROVED LEAVE AND MAY BE GROUNDS FOR
IMMEDIATE DISMISSAL.
I have read and received a copy of this statement and fully understand my
responsibilities in this matter.
EMPLOYEES SIGNATURE:_________________________________________

DATE:_____________________________________

(Revised June 2014)

MEDICAL PRIMARY PROVIDER LIST


FOR SEMINOLE COUNTY SCHOOL BOARD
As your employer, we want to make sure that you get the proper medical treatment as soon as possible so
that you can recover completely and continue to earn 100% of your income. Therefore, there are
designated local medical providers to render the necessary medical treatment for our employees.
SEMINOLE COUNTY SCHOOL BOARD DESIGNATED MEDICAL PROVIDERS:
*Employees may visit any Solantic or Centra Care center in Seminole or Orange County, or any center on
this list. Visit www.carespot.com or www.centracare.org for a listing of locations.

CARE SPOT EXRESS


HEALTHCARE
(All Central Florida Locations)
LAKE MARY
136 Parliament Loop, Ste.102
Lake Mary, Florida 32746
(407) 333-0160
WINTER SPRINGS
5355 Red Bug Lake Road
Winter Springs, Florida 32708
(321) 304-3300
APOPKA
3840 East S.R. 436, Ste 1000
Apopka, Florida 32703
(407) 478-3202
ORLANDO
(Fashion Square)
4301 East Colonial Drive
Orlando, Florida 32803
(321) 319-0212
ORLANDO
2323 South Orange Avenue
Orlando, Florida 32806
(407) 418-9999

HOSPITALS
*Use only after 11 PM or if Injured
Employees are Transported in
Ambulance - Patients seen based
on Medical Priority

CENTRA CARE
(All Central Florida Locations)

CENTRAL FLORIDA
REGIONAL HOSPITAL
1401 West Seminole Boulevard
Sanford, Fl 32771
Phone: (407) 321-4500
SOUTH SEMINOLE HOSPITAL
555 West State Road 434
Longwood, FL 32750
Phone: (407) 767-1200
ORLANDO REGIONAL
HEATHCARE SYSTEM
1414 Kuhl Avenue
Orlando, FL 32806
Phone: (407) 841-5111
FLORIDA HOSPITAL
EAST ORLANDO
7727 Lake Underhill
Orlando, FL 32822
Phone: (407) 303-8110

SANFORD
4451 West 1st Street
(State Road 46)
Sanford, FL 32771
Phone: (407) 330-3412
LONGWOOD
855 South U.S. Highway 17-92
Longwood, FL 32750
Phone: (407) 699-8400
OVIEDO
8010 Red Bug Lake Road
Oviedo, FL 32756
Phone: (407) 977-3677

WINTER PARK
MEMORIAL HOSPITAL
200 N. Lakemont Ave
Winter Park, FL 32792
Phone: (407) 646-7000
Any other Florida Hosp
Affiliation

WATERFORD LAKES
250 North Alafaya Trail Suite 135
Orlando, Florida 32825
(407) 381-4810

ALTAMONTE SPRINGS
440 West State Road 436
Altamonte Springs, FL 32714
(407) 788-2000

NOTE: If you have questions about your workers compensation benefits, contact Karey Edwards at (850) 414-0818 x315, Krista
Casey (850) 414-0818 x318, or Rhonda Brock, RN (Nurse Case Manager) at (850) 414-0818 x312.
NOTE: In emergency situations you may immediately seek treatment from the nearest qualified facility or provider. All medical
treatment must be precertified by contacting FSBIT at (850) 414-0892 x315 Monday through Friday from 7:30 AM until 5 PM.
Emergency treatment must be precertified within 48 hours of the provision of care. You or your provider can initiate the
precertification contact. Precertification appeals can be initiated at the same number.

(Revised June 2014)

MEDICAL REPORT FOR TREATMENT FORM


FOR SEMINOLE COUNTY PUBLIC SCHOOLS WORKERS
COMPENSATION
EMPLOYER/EMPLOYEE INFORMATION
Workers Compensation Processor complete and provide
to the injured worker prior to visit with approved medical
provider.
Injured Employee ________________________________
Position/Job ____________________________________
Describe Injury __________________________________
_______________________________________________
Date of Injury ____/____/____ Time _______AM/PM

EMPLOYEE AUTHORIZATION FOR RELEASE OF


MEDICAL INFORMATION
I hereby authorize the medical provider completing this to
provide Seminole County School Board and/or their
workers
compensation representative(s)
with all
information pertaining to my work-related injury including
my applicable medical history, physical condition and
treatment provided to me.

__________________________________________
Employees Signature

Work Location Name______________________________


Work Location # ____________Phone # ______________

__________________________________________
Date

Processors Signature ____________________________


Date _____________________

NOTE TO TREATING PHYSICIAN AND EMPLOYEE


LIGHT DUTY, RESTRICTED OR MODIFIED DUTY. SCSB will make reasonable efforts to provide the employee with light,
restricted or modified work in accordance with restrictions stated below, when the employee is released by the medical provider
to return to light duty or modified duty prior to discharge at maximum medical improvement. Accommodations after discharge at
maximum medical improvement will be provided in accordance with law.
If hospitalization is necessary, or if the employee is unable to return to normal or modified work within three days, please notify
the employees supervisor at the above number.
CALL FSBIT FOR PRECERTIFICATION AT (850) 414-0818 x315 or x312 for all non-emergency hospitalization or surgery,
physical therapy or chiropractic treatment.
TO REFER TO ANOTHER PROVIDER CALL: the Nurse Case Manager, Rhonda Brock, RN at 850-414-0818 x 312
MEDICAL INFORMATION/REPORT (To Be Completed By Medical Provider)
Diagnosis/Treatment_____________________________________ Medications _______________________________
Patient is released to
Normal Duties
Restricted Duties As Of _____/______/______ Time ________ AM/PM
IF PATIENT IS RELEASED TO RESTRICTED/MODIFIED DUTIES, THE FOLLOWING RESTRICTIONS SHOULD
APPLY FOR _______ # DAYS, FOLLOWING WHICH TIME NORMAL DUTIES CAN BE EXPECTED. (CHECK ALL
THAT APPLY.)
1.
No lifting/carrying over
5 lbs.
10 lbs.
25 lbs.
35 lbs.
50 lbs.
2.
No squatting/kneeling
3.
No bending/stooping
4.
No standing/walking
5.
No driving
6.
Must keep wound clean/dry
7.
Needs to sit/stand as needed
8.
May not work with
left
right
hand/arm
foot/leg for ______ day(s)
9.
May work part-time only for ___ __hours/days for____ day(s) ____ week(s) Other (Specify) _________
10.
Completely disabled from working until ____/____/____
Follow-up appointment is needed with___________________________on ______/______/______
Physicians Name_______________________________________ Telephone Number_______________________
Physicians Signature___________________________________ Date__________________________________
PLEASE FAX THIS FORM TO THE FSBIT NURSE AT (850) 414-0893 IMMEDIATELY UPON EXAMINING PATIENT.

(Revised June 2014)

10

Florida School Board Insurance Trust


Workers Compensation Prescription Information
Please fill out employee information below and provide employee with this document to take to any
pharmacy with prescriptions.

(Revised June 2014)

11

PARTICIPATING PHARMACIES
FOR SEMINOLE COUNTY SCHOOL BOARD
WORKERS COMPENSATION
**An injured employee is entitled to use any pharmacy or pharmacist dispensing and
filling prescriptions for medicines of his/her choice. Below are a few known
companies that use the myMatrixx Prescripton Program. If your preferred pharmacy
is not listed, please view our website for a more complete list of participating
pharmacies.

1. WALGREEN DRUGS

2. WAL-MART

3. WINN-DIXIE

4. PUBLIX

5. TARGET

6. RITE AID

7. MEDICINE SHOPPE

8. CVS

(Revised June 2014)

12

CHOICE FORM
FOR SEMINOLE COUNTY SCHOOL BOARD
WORKERS COMPENSATION OPTION FOR PAYROLL

School Board policy provides up to a maximum of ten (10) days per fiscal year of IN LINE OF DUTY
LEAVE for employees injured in the performance of official duties. If after using the ten (10) IN LINE OF
DUTY LEAVE days you are unable to return to work AND have qualified to receive workers
compensation benefits, you will be paid two-thirds (0.6667) of your average weekly wage up to the
maximum compensation rate established by law, from our workers compensation provider, FSBITFlorida School Boards Insurance Trust. You may elect to use your accrued sick leave or vacation leave to
cover one-third (0.3333) of each day of workers compensation absence which is not paid by FSBIT.
If you elect to use accrued sick leave or vacation leave, one-third (0.3333) of a day will be charged to your
accrued leave balance for each day of workers compensation absence. Your bi-weekly gross pay will
reflect a reduction of two-thirds of a days pay for each day of workers compensation absence which will
be reimbursed to you by FSBIT (Florida School Boards Insurance Trust). If you elect this option, your
School Board pay will be received on your regularly scheduled pay dates.
Please indicate below the option you wish to take. This form must be completed and returned to the
PAYROLL SPECIALIST for your school.
*NOTE: A one week lag will occur in reporting workers compensation absentee data therefore, a final
adjustment of pay (+ or -) will be made to the employees first regular paycheck following his/her return to
duty.
OPTION 1:
I authorize the School Board to deduct from my accrued sick leave balance, one-third (.3333) of a
day for each day of workers compensation absence.*
OPTION 2:
I authorize the School Board to deduct from my accrued vacation leave balance, one-third (.3333)
of a day for each day of workers compensation absence.*
OPTION 3:
I authorize the School Board to use both sick and vacation leave to cover my workers
compensation absence.
Please indicate which type of leave should be used first.*
Sick___________ Vacation _____________
OPTION 4:
I do not wish to use sick or vacation leave for any absence related to this injury.*

Employee Signature

Date of Injury

Print Name

Current Date

Social Security Number

School/Department

(Revised June 2014)

13

TEMPORARY STAFFING EMPLOYMENT AGENCIES


(for Workers working through Temporary Staffing Agencies or any other Non-SCSB Worker,
injured while providing services on SCSB Property)

**Please do not fill out the The First Notice of Illness or Injury Form (DFS-F2-DWC-1) for
Temporary Staff Employees .
Temporary Staffing Employment Agencies Workers Compensation Contacts:
AUE (American United Employers)
777 East Altamonte Drive, Suite 102
Altamonte Springs, Florida 32701
Karen Morris/Terry Wiseman - Contact
(321) 397-2555 x349 Phone
(321) 946-5643 Karen Cell
(407) 666-7381 Terry Cell
(407) 788-3384 - Fax
Compass Home Health Care
452 Osceloa Street
Altamonte Springs, Florida 32751
(888)611-0001- Valerie Jeune
(305) 491-4308 Bernadette Rodriguez
Fast Track Staffing
5166 East Colonial Drive, Orlando, Florida 32803
(352) 922-2040 x202 Margaret Renaud
(352) 622-2040 x 204 Chrystal Ramsay

On Target Staffing
16 South Semoran Blvd., Orlando, Florida 32803
(407) 277-9299 Judy Bonet
(407) 277-1007 Priscila Ramirez

Sunrise Staffing
4699 North SR 7, Suite 5, Tamarac, Florida
(800) 457-0971 Jean Guillaume
(800) 889-0418 Guerline Majuste
(800) 889-0418 - Fax
Top Talent
210 Bumby Avenue, Suite A, Orlando, Florida 32803
Frances Garcia - Contact
(407) 896-2150 Phone
(407) 896-2151 Fax
Tri-State Employment
160 Broadway,
New York, NY 10038
Phyliss Bianco Contact
(212) 346-7960 Phone
(212) 964-7457 - Fax

Manpower Hospitality
445 West SR 436, Suite 1013
Altamonte Springs, Florida 32701
Ray McArdle - Contact
(407) 857-6161 Phone
(407) 697-6341 - Cell
(407) 859-3760 Fax

Injured Worker: Please contact your Temporary Staffing Employment Agency immediately upon receipt of this
form. The above is a list of some of the temporary staffing employment agencies that provide services to SCSB.
If your company is not listed above, please contact your supervisor immediately to obtain the proper procedures
for reporting an on the job injury.
If you have any questions regarding your injury, please contact your employer, immediately.
*By signing this form below, you are acknowledging that this form was given to you on the date
indicated, and that you will contact your employer immediately.

Temporary Workers Signature

Printed Name

Social Security Number

Date of Accident

Temporary Workers Employer

Current Date

Signature of Person Verifying Receipt of Form

Print Name and Title of Verifying Person

(Revised June 2014)

14

Here are just a couple Work Comp issues that keep coming up:
1. NEVER use a previously submitted First Report of Injury even if it is for the same
employee. A new document must be used each time. When old forms are
used, information does not get changed such as dates, social security numbers,
employee positions, etc...
2. Please remember to fax or send via courier the SIGNED First Reports of Injury to
Dawn Lobkovich ASAP. The original signed FROI stays at the cost center. Risk
Management only get a copy. If the employee is unable to sign, please send it
to Dawn upon their return.
3. Be sure to E-MAIL the ELECTRONIC version as well to Dawn as scanned
copies will not upload. The electronic version will not have a signature on
it.
4. FSBIT Adjusters: Karey Edwards, handles last names A-0, (800)790-2118 Ext
315 and Krista Casey, handles last names P-Z, (800) 790-2118 Ext 318
FSBIT FAX: (850) 414-0893
5. Please remember to fax (5-0411) or send via courier any notes from the
doctor to Dawn Lobkovich as well as the assigned FSBIT adjuster.
6. All bug bites, bee stings etc MUST be pre-approved by FSBIT before sending
any employee for treatment. Of course, if they are allergic and are having a life
threatening emergency, respond as you would to any emergency.
7. If an injury is ESE related, please indicate that on the Occupation line. (Ex:
Teacher-ESE)
8. WC Weekly Report: Please submit a response EACH WEEK with SPECIFIC
dates the employee is out even if they are out for an extended period of time. I
will also need notification of the specific DAY they returned from WC. In-LineOf-Duty days are only used for days that a DOCTOR specifically puts an
employee out of work. We do not key employees out for follow-up
appointments with the doctor. The employee is expected to return to work after
the appointment or report to work prior to an appointment if there is reasonable
amount of time to do so. We do not key in partial In-Line-Of-Duty days.
9. If an employee is put on light duty and the school cannot meet the light duty
restrictions, an administrator is to contact David Apfelbaum immediately to
discuss other options. His contact number is (407)320-0208.
10. It is mandatory that the Work Comp Posters are posted in all staff work
rooms, mailrooms and the cafeteria staff dining room. Please contact
Dawn if you need more. Both the English and Spanish version need to be
posted.

(Revised June 2014)

15