COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. James Conrad Bob Taft : Administrator/CEO Transitional WorkGRANT$ Index No. Governor Better Workers’ Compensation Built with you in mind. www.ohiobwc.com 1-800-OHIOBWC : Instructions: •Work with your transitional work developer to complete Sections I to IV. •Submit your reimbursement package to: BWC Transitional WorkGRANT$ Plaintiff(s) P.O. Box 15335 Columbus, OH 43215-0335 -against- Reimbursement Request Calendar No. : JUDICIAL SUBPOENA : Check to make sure your completed reimbursement package contains the following: : Transitional WorkGRANT$ Reimbursement Request (TWG-100) and program narrative Transitional WorkGRANT$ Program Agreement (TWG-110) Copy of developer’s invoice One job analysis : Section I Employer information Employer .name . . . . . . . . (DBA) Defendant(s) : . . . . . . . . . . . . . . . . . . Contact name. . . . . . . . . . . . . . . . . . . ........ Employer address City BWC policy number Telephone number ( ) Employer e-mail address Transitional work developer name Developer e-mail address Managed care organization (MCO) name Type of industry ZIP code State THE PEOPLE OF THE STATE OF NEW YORK Budget TO Manufacturing Office work Telephone number ( ) Service Public employer Have you used these programs or services? Safety Grants GREETINGS: Premium Discount Program Safety and Hygiene Services 10-Step Business Plan Light-Moderate Duty / Transitional Work Program Drug Free Workplace Programs BWC-accreditation number Program Other Partial Full Other WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of information of in room Budget, on the day , 20 , at o'clock in the noon, and at any recessed Using the grid below, locate your base rate and maximum number witness in thisallowed on theon the number of employees. Enter the or adjourned date, to testify and give evidence as a of job analyses action based part of the Section II base rate in the Amount column. Next, list up to the maximum number of job analyses and reimbursement amount. BWC will pay 80 percent of the reimbursement amount up to a maximum of $160 for each job analysis. That means for a job analysis conducted at $200, BWC will reimburse 80 percent or $160. Enter that amount and total the column. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Reimbursement •Please remember to include a copy of Category Amount amount the party ondeveloper’s invoice subpoena was issuedNumber maximum penalty of80% limit all damages sustained as a whose behalf this for a $50 and your transitional work result of your failure to comply. Base rate with your request. 76543210987654321098765432121098765432109876543210987654321 76543210987654321098765432121098765432109876543210987654321 76543210987654321098765432121098765432109876543210987654321 76543210987654321098765432121098765432109876543210987654321 76543210987654321098765432121098765432109876543210987654321 76543210987654321098765432121098765432109876543210987654321 Witness, Honorable Court in County, x Job analyses day of Number of employees 1-49 50-74 75-99 100-124 125-149 150-174 175-199 200+ = x , one.80the Justices of the of , 20 Base rate Maximum job analyses Total $1,000 10 type name below) $1,200 (Attorney must sign above and Indicate grant number for 10 employers eligible for three grants $1,400 10 $1,600 15 1st 2nd 3rd $1,800 Attorney(s) for 15 $2,000 15 $2,200 15 $2,400 20 •Public and private employers with approximately 500 employees are eligible for Office and P.O. Address up to three grants for departments or divisions using the above grid. To best of my knowledge, the information I completed on this form is correct. Authorized employer signature and title BWC-2989 (Rev. 5/30/2003) TWG-100 Date signed Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Sections III and IV on back American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Transitional WorkGRANT$ program narrative Section III Index No. Attach a narrative describing how each of the five elements below will contribute to your No. : Calendar organization’s transitional work program. Listed below are standards that need to be included in a good transitional work program. Your transitional work developer should assist you in summarizing this information. Plaintiff(s) : JUDICIAL SUBPOENA 1. Corporate analysis – Describe your current organizational status, barriers and program objectives. -against: • Demographic information – number of employees, job classifications, union and managed care organization (MC0) information • On-site interviews with employer, employees and/or their representatives: • A review of accident reporting, current modified-duty programs, dispute procedures and return-to-work policies • Barriers to the implementation of a Transitional WorkGRANT$ program : • Recommendations for improvement to the current system • Transitional work goal Defendant(s) : ...................................................... 2. Employee/employer relations – Describe your approach to development of a joint management/employee team for program planning and implementation. Include evidence that both management and employees have contributed to the Transitional WorkGRANT$ program development. Please include union participation in the grant process where applicable. 3. Policy and procedure development Describe your policies THE PEOPLE OF THE STATE–OF NEW YORK and procedures to support program implementation. A policy and procedural manual is essential to the development of a sound Transitional WorkGRANT$ program. The manual should demonstrate a program that is customized and progressive. The manual must include: TO • Employer’s mission statement; • Outline of the dispute-resolution policy; • Program eligibility, entry and exit guidelines, Americans with Disabilities Act of 1990 compliance, etc.; • Roles and responsibilities and how those are communicated to all parties (MCOs, third party administrators, BWC, employer representatives, vocational rehabilitation professionals, hospital/clinic representatives, etc.); GREETINGS: plan for all employees, direct supervisors and top management; • Training • Community resources including physicians, vocational rehabilitation professionals, physical therapy/occupational therapyCOMMAND YOU, that all business and excuses being laid aside, you and each of you WE clinics, etc.; • Evaluation the Honorable process; at the Court • Development of additional policies and procedures based on employer’s needs. attend before located at County of in room day of 20 at noon, and at any recessed 4. Job analyses – The , on the job analyses will include and identify the, following ,information: o'clock in the • Job title with a testify description; or adjourned date, to summary and give evidence as a witness in this action on the part of the • Essential job functions in functional terminology; • Essential job functions divided into functional job task elements; • Physical demands for the job task elements which are analyzed at the job site with the worker’s input using devices to measure forces; Your failure to quantified using actual measurements. This will include contempt of and/or duration make you liable to • The physical demandscomply with this subpoena is punishable as aforces, frequencycourt and willand postures; the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result•ofEquipment or tools used by the worker to perform the job tasks; your failure to comply. • Work environment; • Creation of job banks with physical demands as transitional job tasks may be developed; • Ergonomic concerns, safety considerations and recommendations for job modifications , onenot be a part of the of the need of the Justices job Witness, Honorable analyses. They should be addressed with the employer. Recommendations and referrals should be made to the appropriate Court incommunity resources, such as BWC’sday of of Safety & Hygiene. County, , 20 Division 5. Program evaluation – Describe your evaluation process for measuring the effectiveness of a Transitional WorkGRANT$ program from employer and employee perspectives. Areas measured should include, but are not limited to, the following: (Attorney must sign above and type name below) • Workers’ compensation cost-savings analysis; • Productivity measurement; • Worker/management satisfaction; • Process for follow up with your developer to discuss program improvement with time frame. Attorney(s) for Section IV Statement of MCO involvement with employer •Your answers in this section will not affect the determination of your grant. The MCO named above actively and individually either encouraged our organization to apply for an Ohio BWC Transitional WorkGRANT or referred our organization to a transitional work developer. Office Yes P.O. Address and No This MCO participated with our organization and the transitional work developer, physically attended one or more meetings, in creating the transitional work program. Yes No Authorized employer signature and title Transitional work developer signature Date signed Telephone No.: Facsimile No.: Date signed E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com ,