Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Program Overview

  • Name and position of person responsible for the hospital non-subscription program.

  • When did the facility begin the non-subscription program (opted out of Workers Compensation insurance?

Required Data

  • Is the DWC Form-005 filed each year between February 1 and April 30 each year?

  • Is the DWC Form-005 filed electronically each year?

  • Is the DWC Form-005 filed by a hard copy (not electronically)?

  • Is the DWC Form-007 completed and sent to the TDI Division of Workers Compensation EACH Month?

  • Does the DWC For-007 include the following:

  • When filing the DWC Form-007, is an injury data sheet completed on EACH employee injured during the reporting period?

  • Does the DWC Form-007 include all Full time, Part time and Temporary employees?

  • Is there a posted notice that the facility has no workers compensation coverage where the employee can see it regularly?

  • Is the posted notice of non-coverage provided in Spanish or other appropriate language?

  • Is the written notice of non-coverage provided to each new employee?

  • Is a copy of non-coverage signed and dated by the new employee and a facility representative and filed in the new employee's personnel file?

  • For each employee accident or illness, is there an internal report completed?

  • When there is an accident or illness, where is the report sent within the hospital?

  • What is the established time frame that the accident/illness report must be completed?

  • Name of department and position that reviews each injury report.

  • If the accident or illness reported is reviewed and questioned regarding on-the-job event is work related, what are the procedures taken?

  • Is there current information available regarding who to contact when there is a potential for denial of the claim?

  • Is there an IMMEDIATE follow up by a supervisor following an accident or illness specifically in regard to causes.

  • Is there a third party administrator available to the hospital when there is a question regarding the validity of the accident/illness report?

  • Is there a corporate contact person that is available to discuss accident/illness issues?


  • Are all new hires provided safety training with specifics of the non-subscription program PRIOR to beginning their position?

  • Is ALL training for new hires documented and filed for future references?

  • Is safety training provided to ALL employees and documentation regarding the type of training for all employees maintained for future references and includes dates of training?

  • Is annually safety training to ALL employees based on accident trends?

  • Is there a safety or hazard reporting system available to all employees with follow up?

  • Does the equipment management program include documented training on the safe use of all equipment and includes patient and non-patient equipment for EACH employee?

  • Is there a committee (EOC) or subcommittee that meets monthly and safety issues or safety hazards addressed?

  • Is there any outside assistance used to enhance the facility employee safety program?

  • Is the Texas Department of Insurance (TDI) used for safety training?

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