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 Worker's Compensation Instructions and Forms



Worker’s Compensation Instructions


Injury Reporting


The supervisor/manager, at first knowledge of an alleged job related injury or illness, arranges for immediate medical attention.  The employee has the option of going to the doctor of his/her choice as long as they will accept Federal Worker’s Compensation Insurance.  The employee cannot go to a chiropractor unless he/she has special approval by AFPC Worker’s Compensation Section.


Simplified Claims Procedures


At the time of injury:


1.       LS-1, Request for Examination and/or Treatment, is provided to the employee before treatment.  In an emergency situation the supervisor/manager will provide the form to the treating physician or medical facility within 24 hours of injury.


NOTE: If employee elects not to receive treatment, have the employee sign and date Declination of Medical Treatment Statement.  Supervisor also signs and dates the statement.  Forward to the HRO as soon as it is completed.


a.       Part A items 1 through 13 are to be completed by the supervisor/manager.  If the claim is questionable, check item 7b.


b.      Part B is to be completed by the treating physician.


c.       Forward form to the HRO as soon as it is completed.


2.       Notify HRO, 226-4417


Within 24 Hours of Knowledge of the Injury:


1.       LS-201, Notice of Employee’s Injury or Death, completed by employee.  Must be from the employees’ point of view.


a.       Provide employee or family member with LS-201 and have him/her return it to you as soon as possible.  Forward to the HRO.


2.       LS-202, Employer’s First Report of Accident or Occupational Illness, completed by the supervisor/manager. 


a.       Item 15 may be left blank if the employee has not returned to work or the date of the employee’s return is not known.   Complete all other items except blocks 1 and 2, which will be completed by the HRO upon receipt.


b.      Item 23a, fill in hourly wage.


3.       AF-786, Authorization for Release of Medical Information, completed by employee. 


a.       When medical care is required, have employee complete and sign this form and immediately return to the supervisor/manager.  The supervisor or manager will forward to the HRO upon receipt.






If A Follow Up Doctor Visit Is Required:


1.       LS-204, Attending Physician’s Supplementary Report, completed by physician.


a.       If a follow-up doctor visit is required the supervisor/manager will provide the employee with an LS-204 for the doctor to complete.  The employee should return the LS-204 to the supervisor after the doctor has completed it. Forward the LS-204 to the HRO immediately upon receipt. 


When Employee Returns to Work:


1.       LS-210, Employer’s Supplementary Report of Accident of Occupational Illness.


a.       When the employee returns to work the supervisor/manager must complete the LS-210 and forward it to the HRO within 24 hours of the employee’s return to work.


b.      If the employee beings losing time from work again, the supervisor/manager completes a new LS-210, showing all previous time lost, and forwards it to the HRO within 24 hours of the date the employee again beings to lose time.  Again, when the employee returns to work the supervisor/manager completes a new LS-210 and forwards to the HRO within 24 hours of employee’s return to work.


c.       A LS-210 is needed each time the employee begins losing time and he/she returns to work.  Make certain all previous time lost is shown on each new LS-210 accomplished.


If Disability Exceeds 6 Weeks:


1.       AF Form 272, NAF Supervisor’s Report.


a.       The supervisor must complete this form and submit it to the HRO, who will, in turn, forward it to HQ AFSVA/SVXBW.




Important Reminders


1.       The supervisor/manager is responsible for maintaining close contact with the employee who is losing time from work.  This is to assure him/her that the NAFI has a genuine interest in his/her recovery and to assist in matters relating to the workers’ compensation claim.


2.       Instruct the employee to submit to the HRO all itemized medical billings for payment as well as the completed LS-204, which certifies the employee’s disability.


3.       Never deny an employee the right to file a workers’ compensation claim.


4.       Give injured employee a copy of the Employee’s Responsibilities handout.


5.       Notify the individual identified on the 971 as an emergency contact if the injury or illness is seriously disabling.  In the case of the employee’s death, immediately contact HRO.


6.       All forms must be legible, signed and dated; this could make or break a case that needs to go before legal review.


7.       Every employee is entitled to select his or her own physician; however, the employee is limited to one free choice of physician.  Treatment at an emergency facility is not considered a free choice; therefore, if an employee must go to an emergency facility, he/she is entitled to select his/her own care provider for any follow-up care needed.


8.       Benefits are not payable for the first 3 calendar days of disability unless the period of disability extends for more than 14 days.  In that case, the benefits would be retroactive to the first day.  Compensation is not authorized for a doctor’s appointment or treatment if the patient has been released back to work.


9.       Request, through the HRO, that the AFPC Worker’s Compensation Section review the case as soon as there is a reason to doubt that an employee is entitled to benefits.  This must take place within 5 days of the time knowledge of the facts giving rise of doubt gained.


10.   If the employee is out due to a worker’s compensation injury and they are being paid disability from worker’s compensation, LWOP needs to be recorded on their timesheet.


Sick Leave Option (Regular Employees)


TTD and TPD may be supplemented from available sick leave or annual leave so the employee’s combined income from disability benefit and the leave payment equals, but does not exceed 100 percent of an employee’s wage at the time of injury.  An employee may initiate this action by completing and submitting an OPM Form 71.




1-Employees-Responsibilities.pdf 1-Employees-Responsibilities.pdf
3-Workers-Compensation-Claim-Instructions-Supervisors.pdf 3-Workers-Compensation-Claim-Instructions-Supervisors.pdf
2-Workers-Comp-Supervisor-Checklist.pdf 2-Workers-Comp-Supervisor-Checklist.pdf
4-LS-1.pdf 4-LS-1.pdf
7-LS-204.pdf 7-LS-204.pdf
5-LS-201.pdf 5-LS-201.pdf
6-LS-202.pdf 6-LS-202.pdf
AF786.pdf AF786.pdf
LS-210.pdf LS-210.pdf

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