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:
- A work related or on-the-job death
- An employee absent from work more than1 day as the result of on-the-job injury
- Knowledge of occupational disease
-
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?
-
Training/education
-
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?
-
undefined