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DocuSign Envelope ID: 716FBOE9-5CE9-44F5-9BAC-48D7E4C96CD6 <br /> UCG <br /> Center <br /> New North Carolinians <br /> September 23,2014 <br /> To Whom It May Concern: <br /> This letter is to verify that as a full-time AmcriCorps member in the A1nerlCorps Cross Cultural <br /> Education Service Systems (ACCESS)Project at the University of North Carolina at Greensboro, Asif <br /> Alain Khan,is considered to be a Temporary State Employee. Therefore,Mr. Khan is eligible to apply <br /> for the North Carolina Worker's Compensation. Below is a policy that is included in the ACCESS <br /> Project's Member Manual regarding the North Carolina Worker's Compensation for UNCG employees <br /> including AmcriCorps member's who receive monthly stipend from the program. The Member Manual is <br /> distributed to each of the AmcriCorps member accepted in the program. <br /> "All UNCG employees, including stipend AneriCorps ACCESS members, are covered by North <br /> Carolina Workers' Compensation. Any stipend AmcriCorps mernber who suffers an accidental injury or <br /> contracts an occupational disease within the provisions of the Workers' Compensation Act is entitled to <br /> benefits provided by the Act. <br /> COMPENSABLE INJURY <br /> All injury is compensable under Workers' Compensation if it meets the following criteria: <br /> • The injury was caused by an accident. (In case of hernia or injury to the back, the injury is <br /> compensable only if it is the result of a specific traumatic incident of the work assigned.) <br /> • The injury arose out of the employment. <br /> • The injury was sustained in the course of employment, <br /> RESPONSIBILITY OF AMERICORPS MEMBER <br /> Notice to Supervisor <br /> 1. The member must notify their site supervisor and the AineriCorps ACCESS Director <br /> immediately, in writing,using UNCG HRS Form 301 (Accident/Injury/Illness <br /> Investigation Report). <br /> a. The written notice may be handwritten or typed and should indicate the date of <br /> the accident(or approximate date when occupational illness was contracted),how <br /> the accident occurred (cause of illness), and the nature and extent of injury <br /> (illness). It should also note whether or not the employee had to miss work <br /> because of the accident and,if so, the expected or actual return-to-work date. <br /> A s ; <br /> CeTt il�rlgLs........:: <br /> [yr[t�ral DEVersily Unite <br /> 915 W.Lee St. Suite A,Greensboro,NC 27403 Phone(336)256-1060 Fax(336)334-5413 &50fduffld"„" <br />