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DocuSign Envelope ID: 716FBOE9-5CE9-44F5-9BAC-48D7E4C96CD6 <br /> UNCG <br /> Centerk� <br /> Neu,North Carolinians <br /> 2, The ACCESS Director will then submit Form 19 (Employer's Report for Injury or <br /> Occupational Disease to the Industrial Commission), Form 18 (Notice of Accident to <br /> Employer), HRS 301, and EE Statement form to the UNCG Department of Human <br /> Resource Services and the Office of Safety within 48 hours after the occurrence or <br /> knowledge of an injured member(GS 97-92). <br /> 3. Forms may be obtained by contacting the Office of Safety,the UNCG Department of <br /> Human Resource Services, or you may go to the UNCG Human Resource Services web <br /> site at www.uncg.edu/lirs and select Workers' Compensation Program, <br /> The Workers' Compensation Act requires that a member give written notice to the <br /> ACCESS Director and Site Supervisor within 30 days of an accident or within 30 days of <br /> being diagnosed as having a disease associated with employment. After 30 days no <br /> compensation is payable without a ruling by the Industrial Commission. <br /> Obtaining Medical Cafe <br /> A member who is injured on the job or who contracts an occupational disease must go to the <br /> University's Student Health Center for medical care. For additional information, see the UNCG <br /> staff policy manual,which can be found at. <br /> http://ureb.uneg.edu/lirs/Pol icyManuals/StaffMatival/sections/-vN,orkers_coml <br /> Return to Service (Same Day) <br /> After treatment by a physician following a work-related accident,the member is expected to <br /> return to service unless the treating physician indicates the member must go home for the day. <br /> The member is responsible for obtaining from the treating physician a written statement <br /> certifying the need to go home instead of returning to service. <br /> Return to Service (After Workers'Conymnsation Leave) <br /> A member who has been released by the treating physician to return to service has the obligation <br /> to accept any suitable service assignment provided by the site supervisor that is in keeping with <br /> the member's capability. Refusal to accept suitable service assignment will result in termination <br /> of compensation and may result in dismissal. <br /> ACCEPTANCE OR DENIAL OF CLAIM FOR WORKERS' COMPENSATION <br /> 6 The CorVel Corporation(University Third Party Adininistrator)has responsibility for <br /> determining whether or not the University is liable for the claim for workers'compensation <br /> benefits. The decision is made on the basis of all the facts presented on the member's notice and <br /> the discussions with the site supervisor,ACCESS Director and the University Compliance and <br /> Safety Officers. Payment of medical bills by the University is not an indication of the <br /> University's acceptance of liability for the claim, <br /> e If the claim is denied,the member will be notified as soon as possible,pending receipt of <br /> medical documentation if necessary. To petition further, the member must file'a written notice of <br /> r <br /> tcbrlttn9 S <br /> [u11— Ulrer,H Unily`I'�� <br /> 915 W.Lee St. Suite A,Greensboro,NC 27403 Phone(336)256-1060 Fax(336)334-5413 <br />