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User Manual June 2002

1. The station specific safety information includes the Safety Official Name Safety Official Title Safety Phone Number and Safety Phone Extension June 2002 ASISTS GUI V 2 0 User Manual 71 Option Documentation Enter Edit OSHA 300A Summary Data The station specific industrial information includes the Industry Description Standard Industrial Classification SIC code and North America Industrial Classification NAICS code For an integrated site the industrial information must be entered for each station e Industry Description free text no special characters such as 4 amp lt gt required field e Standard Industrial Classification SIC numeric value must be 4 digits with range 0000 9999 table driven e North America Industrial Classification NAICS numeric value must be 6 digits with range 000000 999999 table driven The Month Year specific OSHA 300A summary information consists of the Average Number of Employees and Total Hours Worked By Employees per month for the current year When the safety official chooses to enter edit OSHA 300A information the following data fields are included e Month defaults to current month selectable values are January through December calendar year e Average Number of Employees and Total Hours Employee Worked information is entered by month per year This information is required The monthly OSHA 300A Summary information can be edited for the current ye
2. 34 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 Physician Tab Information pertaining to the physician and medical treatment is contained here Worker s Compensation Validate and Sign CA 2 form Select Claim Signe anaes enero eR v SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OWCP Physician First Providing Medical Care m Medical Physician Name Date Employee first received medical care Title z Do medical reports show employee is Disabled for Work Street C Yes 1 C 2 City State x Prev Next gt June 2002 ASISTS GUI V 2 0 User Manual 35 Option Documentation Complete Validate Sign CA2 Signatures Tab Filing instructions and supervisor information such as title and phone number are located on this tab Worker s Compensation Validate and Sign CA 2 form me SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OwcP Signature of Supervisor and Filing Instructions Supervisor who knowingly certifies to any false statement misrepresentation concealment of fact etc in respect of this claim may also be subject to appropriate felony criminal prosecution certif
3. in the SSN or enter the first letter of the last name and last 4 digits of the SSN then Press Search Search Name Person Involved DK Cancel Use this selection screen to either print or print preview selected claim from the list box The Print button sends the printed version of the selected claim to the windows default printer Print Preview displays the report to the screen wis Print Select A CA Claim From the List Box Select Claim Claim Person Date of Incident Type Print Print Preview Exit am oH 90 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Print CA7 U S Department of Labor Claim for Compensation Employment Standards Administration Office of Workers Compensation Programs SECTION 1 EMPLOYEE PORTION a Name of Employee Last First Middle No 1215 0103 ASISTS EMFLOYEE TWENTYTWO Expires 10 31 2008 b Mailing Address fred Cie State ZF Code c OWCP File Number CA 7 001 d Date of Injury e Social Security Number E Mail Address nana Month Day Year g 6 6 0 6 6 6 2 2 SECTION 2 Compensation is claimed for f Telephone No FAX No Inclusive Date Range From To Intermittent a Li Leave without Pay Yes ne Ga to Section S b L Leave buy back L ves Go to Section 3 and Conplefe Fom Ah Other wage loss specify type Yes No Geta Section 3 such as downgrade loss of night ditterential etc Type If
4. Add Ed Delete Per 5 SECTION 3 m Does employee work a fixed 40 hour per week emn T E sens Days C Yes 1 Mon Tue Wed The Mi Sat Show Scheduled Hours for the two weak pay period in which work Stopped Week 1 From Sun E Mon Tuf Wed Thr Fri E Sat I Week 2 From Sun Mon 1 Tue Wed Thr Fri Sat Pay Stopped Week Pay Stopped Day Did employee work in position 11 months prior to injury Would position have afforded Es for 11 months but for the UNES C Yes 3 No 4 C Yes 5 C 6 Prev Next MW Print Sign Validate Save A Exit June 2002 ASISTS GUI V 2 0 User Manual 109 Option Documentation Request for Compensation CA7 Sections 10 13 Tab The Sections 10 13 tab contains health benefits insurance and retirement questions This is also the tab where continuation of pay COP pay status and whether or not the employee returned to work information is entered This tab is available only to workers compensation personnel mu CAT Request for Compensation Form ml x Select Claim Claim Person Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 Sections 8 9 Sections 10 13 Sections 14 15 SECTION 10 date pay stopped was employee enrolled in Health Benefits unde
5. Edit Site Parameter This option can be found on the Safety and Workers Comp Menus The Edit Site Parameter option provides the safety official the capability to create default information for the facility If the site is an integrated facility every station within the network can be defined with default information The information entered here will populate the Agency Station and Physician fields on a CA 1 or CA 2 The default values for the following fields can be set for each station Station Number OWCP Chargeback Code OWCP Chargeback Suffix Physician Name Physician Address Physician City Physician State Physician Zip Code and Physician Title The following information is displayed on the Edit Site Parameter screen Site Name The name of your facility in the Site Parameter file OWCP District Office Department of Labor District office that serves your facility Station List The list of stations that currently have default information entered Station Physician Info Includes the chargeback code chargeback suffix physician name address title gt Edit Site Parameter Site Name EC OWCP District Office BOSTON Station Information Station ALBANY 500 Physician Name UPSTATE NEW YORK HCS 528 LONG BEACH HCS 600 Physician PTE Physician City Physician State Phy Zip Physician Title Add Station Edit Station Delete Station Chargeback Codel Chargeback Suffix amp MARII
6. Print Report of Incident Print Preview mx a gt 55 12 4 51 INCIDENT REPORT CS Vetaans HeatthAdmiristration 2222 22 00 PS DRIVE ALBANY NEW YORK 2210 INJURY ILLHESS DATA SECTION location ofin jury Character ion try E R Emergency Room Rash Clearrup Following Medical Body ct fie ced de of Edy Athotd BOTH FO REARMS Boh Addtonal Body Part Job Trang Fe o tb eal DESCRIPTION OF INCIDENT who wha when where how and why Medica Bnemency RRECTIVE ACTION TAKEN carche action ken Shton ALBANY 500 CASES 2005 00029 Date Created FEBO2 20051435 Croatd CHENJOY Report Fun Ine 4222008 R4951 FM 0 Page 1 of 3 2 96 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Print Report of Incident SHARPS EX POS URE DATA SECTION Patent Source 7 Urkenlfable Perconal Prototw Gear Uced dot atTime Ob Pot Caucing In Godly Ruk Expo aure Soume Pupo ce of Sharp Cb bot Deuce LI EulpmentDe Joe Fallure Cocurred omy De tedoeUced ull Ce doe U ced Inhry Morb De Byaging IE SAFETY OFFICIAL COMMENTS Signature of Safety Signature of Super cor NOTICE OF CONDITIONS UNDER WHICH THIS INFORMATION IS COLLECTED hcan plane wih Privacy Act of 197 4 he 12 prodded 1 Sold Ifonotie Irmaloniz by Ocapalond Sok y and Heallh AcloT 1970
7. hereby claim medical treatment if needed and the following as checked below while disabled for work 14 Nature of injury Identify both the injury and the part of body e g fracture of left leg 0 Page 1 of 4 86 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Print Blank CA1 CA2 CA7 Blank CA2 Print Previ lt Notice of Occupational Disease U S Department of Labor and Claim for Compensation Employment Standards Administration o Office of Workers Compensation Programs Employee Please complete all boxes 1 18 below Do not complete shaded areas Employing Agency Supervisor or Compensation Specialist Complete shaded boxes a b and c Employee Data 1 Name of Employee Last First Middle 3 Date of Birth Mo Day Yr 5 Home telephone 7 Employee s home mailing address including city state and zip code 2 Social Security Number 6 Grade as of date of last exposure Level Step 8 Dependents C wife Husband Children under 18 years Other 9 Employee s Occupation Occupation Code 11 Date you first became aware of disease or Illness Mo Day Yr 10 Location address where you worked when disease or illness occurred Include city state and ZIP code 12 Date you first realized 13 Explain the relationship to your employment and why you came t
8. Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 6 Sections 8 9 Sections 10 13 Sections 14 15 Section 14 Remarks Section 15 employing agency official who knowingly certifies to any false statement misrepresentation or concealment of fact with respect to this claim may also be subject to appropriate felony criminal prosecution certify that the information given above and furnished by the employee on this form is true to the best of my knowledge with any exceptions noted in the Remarks above Title Date Name of Agency Date Claim Form Received from Employee If OWCP needs specific pay information the person who should be contacted is Name Title O Telephone No Ci Fax No o Email Address Sign Validate June 2002 ASISTS GUI V 2 0 User Manual 111 Option Documentation Summary Incident Reports This option can be found on the Occupational Health Safety and Workers Comp Menus under Reports Each report summarizes the number of incidents grouped by various fields The input criteria is the same for each report type The report types are as follows Type of Incidents Occupational Code Characterization of Injury Service Body Part Day of Week Time of Day Summarizes the number of incidents grouped on the critical tracking issues Summarizes the number of incidents grouped by the occupatio
9. Manual June 2002 Option Documentation Create Incident Report Name Search Screen If employee or non paid employee is selected the following Name Search Screen is displayed It allows the user to enter a partial name SSN or last initial and last four of the SSN It returns all the individuals found that match the search criteria and allows the user to select an individual Name Search Screen June 2002 ASISTS GUI V 2 0 User Manual 51 Option Documentation Create Incident Report Duplicate Record Checking To help prevent duplicate records from being created after the individual has been selected the system will check to see if there is a currently Open case for any person with the same SSN If applicable the following form is displayed Duplicate Record WARNING The Specified Individual Has Potential Duplicate Records If one ofthe records below looks like the one you are aboutto create please EXIT without creating a new record ASISTSEMPLOYEE ONE NOY 22 200471 4 00 Exposure to Body Fluids Splash ASISTSEMPLOYEE ONE NOV 04 20041 4 00 Lifting Repositioning Patients ASISTSEMPLO YEE ONE JAN 13 2005 10 30 Lifting Non Patient Care ASISTSEMPL YEE ONE FEB 01 2005 08 00 Not Elsewhere Classified ASISTSEMPLOYEE UNE JAN 15 2005 13 13 Lifting Non Patient ASISTSEMPLOYEE ONE JAN 06 2005 Environmental T oxic Exposure Create New Record If the case currently being entered is a new case and no
10. 2 No Lost Time Medical Expenses incurred 1 No Lost Time and no Medical Expenses i 3 Lost Time covered by leave LWOP or COP certify that the information given above and that furnished by the employee is true to the best of my knowledge with the following 4 First Aid Injury exception Exception PC O SupervisorTitle Office Phone Extension THE EMPLOYEE MUST ELECTRONICALLY SIGN BEFORE THE SUPERVISOR Once you have electronically signed the CA 1 itis your responsibility to Print a hardcopy of the form Sign the hardcopy in blue Ink Have the Employee sign the hardcopy in blue ink Deliver the hardcopy to HRMS immediately Prev Next gt June 2002 ASISTS GUI V 2 0 User Manual 25 Option Documentation Complete Validate Sign CA1 OWCP Tab Information only accessible to OWCP personnel is contained on this tab Worker s Compensation Edit Employee CA 1 Form 26 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA1 Prevention of Dual Benefits In order to prevent a veteran from receiving dual benefits for the same injury or death Federal Employees Compensation Act FECA Section 8116 a Dual Benefits form will be attached to the CAI claim This form must be signed by both the employee and workers compensation personnel indicating that this claim is not a claim covered by another military claim When the employee s
11. 3 Are you sure you want to Delete this record If Yes the Station and all default information will be deleted The following message will be displayed to verify that the station has been deleted Asists Record successfully deleted 64 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Edit Validate Stub Record This option can be found on the Occupational Health Menu This menu option is used to edit the top portion of the Report of Incident The stub record contains basic information related to the incident and the person involved The supervisor and safety official can edit the stub record using the Complete Validate Sign Incident Report option Occupational Health Edit Stub JE o xj Select Claim 2007 00027 OCT 09 2006 ASISTS SOSEMPLOYEE SSN 000 00 0005 Injury lliness Iness disease Personnel Status Volunteer Service Type Incident Environmental T oxic Exposure Employee Data Cost Center Organization Occupation 9999 Grade Step Education m Person Involved 251575 508EMPLOYEE Station Number ALBANY 500 SSN 00000 0005 Date of Birth MAY 05 1935 Type of Incident Environmental Toxic Exposure v Female Male Time Work Began joz 7 Hire Date 22 1963 Home Address m Press Button to Select Supervisor Street 5555 JAWS ROAD Voluntary Svc Super Secondary Supervisor City PLANO ITSUPERVISOR ASIS
12. DETAI DETAI DETAI DETAI DETAI L ENTERED L ENTERED L ENTERED L ENTERED rage Area L ENTERED L ENTERED L ENTERED L ENTERED Dom Room 14 L ENTERED L ENTERED L ENTERED EVEL THREE L ENTERED ss sm 5 0 LU p co ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Location of Injury Report Excel Spreadsheet format E Microsoft Excel Book1 File gdt view Insert Format Tools Data Window 2D 25 be ch B18 7 dh a S Er kL A Lil AG E HP 52 92 2 8448 question for help 8 X Ye Reply with Changes End Review for All Station s Assault Cumulative Trauma Cumulative Trauma Cumulative Trauma Cumulative Trauma Cumulative Trauma Environmental Toxic Exposure Environmental Toxic Exposure Location of Injury Report 3 22 2005 9 18 2005 Grounds Roads Lots BDC Blood Draw Center BDC Blood Draw Center Food Service Area ICU Intensive Care Unit NO LOC ENTERED NO LOC ENTERED Pharmacy Areas DETAIL ENTERED LALALALALS O DETAIL ENTERED NO DETAIL ENTERED NO DETAIL ENTERED DETAIL ENTERED Latex Reaction Allergy Cooling plant Freon Storage Area Latex Reaction Allergy NO LOC ENTERED Lifting Non Patient Care Laundry DETAIL ENTERED Lifting Non Patient Care Lifting Repositioning Patients Lifting Repositioning Patients Materia
13. FECA Seciton 8115 prohibits an employee from receiving workers compensation under the FECA and veterans benefits administered by Veterans Benefits Administration for the same injury or death Name ASISTSEMPLOYEE ONE SSN 666 11 1111 Date of Job Related Injury NOY 22 20041 4 00 Part s of the body involved in job related injury SINGLE EYE you a Veteran you currently receiving veteran Or Do you have a claim for a military connected C Yes C No benefits for a military connected disability disability benefits pending C Yes C No C Yes C No Veteran Benefits Admin VBA Number Part s of body involved in your military claim Condition accepted in your military claim was informed of the regulations involved in filing a claim for Workers Compensation and a claim or increase in my VBA benefit for military connected disability If both are approved understand that must make an election between the two benefits and will notify the Workers Compensation Specialist at my employing facility of what choose Employee Signature Date Signed Workers Comp Specialist Signature Date Signed This form will be filed in your claim for workers compenation benefits and with V Regional Office VBA office Sign Validate Save Est June 2002 ASISTS GUI V 2 0 User Manual 39 Option Documentation Complete Validate Sign Incident Report This option can be found
14. PL 9 E595 5 USC 7902 29 CFR 60 28 USC 2571 90 awi Beculve Order 121961 1960 here auhordles do rolrequre talpena les be Impoared rire lorez pons 041 report 2 Tre pindpal purpose tor which iz Inm ialion is collected Is loprovide s kals ica dala awi andiyrl ofinikury Hress and properlylozz expereince Insupporlotie Deparimenbli Agency Region ard Toe Sok ly and Heal hh Programs az well az required s kals ical summ alons or reports DeparimentotLabor and ober governmental of sinc honc requiring such 3 Roullne ofhi Infomation Inckade ao Proddirg he means tor complying wi h e reporting requirement orbe Occupalaya aw Heal amp clofiS70 29C FR 1960 and sud ober reports m ay be required by legi riae of reguakry obligation b Pradding zudizummary bls Ica dalani analysis a Iz b appropriately ewluab Fe et ctveress othe rat y mansgemenlprogram z and assisi apprcpriale deparimenbi Yanciionz in fe Initalonanid supporlot crecile or preveniue aclor Respawiing ioa cour zubpoenaor cour ofcompe leni Kart z diciionz In acim iha or dif zu lans d Trans tring b Fe appropriale governmental regualoryeniMes whelber deral lale local or ren sehin Televan b ves Igale aciono wena weolalion aras of reguialonis iniicaled The efieclon he indisdual ofniolpr adding ali opal orbe reques Ed im omialion maybe b render Impoz sble of lodelay he Department documerdrg
15. 1 Form Select Claim ROSIE AR a ae a EE SSN Injury lliness Personnel Status Service Type Incident Employee Data Injury witness Data Agency Work Schedule Third Party Physician Filing Instructions OwCP r Regular Work Hours Date Time s 5 From X Date Time of Injury Te gt Date of Notice Received Regular Work Schedule Check the days of the week worked Date Pay Stopped when the Incident occured Sunday Date 45 Day Period Began Monday Tuesday Date Time Retumed to Work Wednsday Thursday mi Pay Rate when Employee Stopped Work Saturday Per eu Prey Next gt 22 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA1 Third Party Tab Information pertaining to the third party and incident specific questions 15 located on this tab Worker s Compensation Edit Employee CA 1 Form a Cee REOET SSN Injury liness Personnel Status Service Type Incident Employee Data Injury Witness Data Agency Work Schedule Third Party Physician Filing Instructions OwCP NOTE Don t include Patient and or Employee as 3rd Party Was Injury caused by Employee s Misconduct Intoxication or Intent to Injure Self or Another Was Injury Caused by 3RD Party C Yes No 6 C Yes 1 C No 2 and Address of Third Part
16. Incident Summary Incident Reports Filing Instructions Report Reason for Controvert Report Reason for Dispute Report 8 ASISTS GUI V 2 0 User Manual June 2002 ASISTS Menus Union Menu The Union Menu is assigned to the union representative members of the Accident Review Board at the facility The Union menu provides the ability to see the Employee of Rights and modified reports without names Users with this menu can access all incidents within their facility The Union contains these options Employee Bill of Rights Reports Display OSHA 300 Log Log of Federal Occupational Injuries and IlIness Print Incident Report Status Print Report of Incident June 2002 ASISTS GUI V 2 0 User Manual 9 ASISTS Menus Common Screens The screens shown below are common to many of the ASISTS options They are displayed here and for the most part not shown in each individual option documentation ASISTS Select Case Screen ASISTS Select Cases You can narrow the list of cases by selecting any all of the criteria listed below Each Criteria is OPTIONAL Select By M All Cases Case Number Person Involved Supervisor M Choose Personnel Status IV All Medical Student Employee Nursing Student Non Paid Employee Other Student Volunteer Contractor Resident Physician Visitor Other Cancel This screen allows the user to narrow the search criteria when selecting a case 10 ASISTS GUI V
17. Report This option can be found on the Workers Comp Menu under Reports The Reason for Dispute Report provides the capability to view the number of dispute code occurrences for lost time and no lost time cases for a single station or all stations within a user specified date range The user is asked to enter a start date end date and either a single station or all stations The report gives a count of the number of each of the following reason for dispute codes for both lost time and no lost time cases A personal emotional reaction to administrative activities Different medical opinions about injury weight of evidence Different stories about what happened Employee did not follow facility policies procedures Inappropriate medical provider Injury was not work related Investigation of incident does not support employee s statement Medical diagnosis treatment not related to claimed condition No medical evidence to support work related injury Timeliness of reporting incident The report will indicate the number of cases in the total count that had data in block 36 State the Reason in Detail and the number of cases not disputed in the report date range Reason for Dispute Report Report Start Date E 15 2006 Report End Date 3 1 2006 v Stations AllStations Single Station Select Single Station Print Print Preview 102 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation
18. Skin Disorder M3 Respiratory Condition MA Poisoning M5 Hearing Loss M6 All Other When there are no OSHA eligible cases to print on the OSHA 300 Log report the system will default a zero in all the report fields The system will display the selected date range and date time the report was generated on the footer of the OSHA 300 Log report June 2002 ASISTS GUI V 2 0 User Manual 59 Option Documentation Display OSHA 300 Log BE gA BS Attentionmt Tom comths tomato rebthg emp byee heat anclmasthe sedh amaner OSHAS Form 300 tiatppect be conte ithiy otenpiyees bre er EYtpos sbe wie Be E Dead Log of Work Related Injuries amp Illnesses M tro ronis cat pU pee t eom Mein T m Yeu mustrecord infimae aboutevery injury or dnes hafimohes loss ofconsciuness restictd work actuit or job tans days away fom work or medical teatnentbeyond You musto record relied njaies andilnes 2e digo sed by a phy or henth care prof sional You must ss record work eld injuries esses batmeetany of be specife recording aitris 29 BOLS trough 1904 12 Fed fee ib use iro lines for a single ou need o You nusteamplee an injury and ess indidentre port OSHA 301 or equivalent french injury iles recorded on tis fm Ey aute wheher is recordable al your beal oce fe hep KEI IIH 2
19. Supervisor Menu The Supervisor Menu may be assigned to any user with supervisory duties The user creating the Incident Record will list the supervisor s of the employee involved The Supervisor Menu provides a variety of tasks to facilitate efficient and accurate incident reporting Users with this menu only see records that have their name listed in the Supervisor or Secondary Supervisor fields on the Report of Incident The Supervisor Menu contains these options Create Incident Report Print CA1 CA2 Complete Validate Sign Incident Report Complete Validate Sign CA1 Complete Validate Sign CA2 Employee Bill of Rights Print Report of Incident Print Incident Report Status Occupational Health Menu The Occupational Health Menu is assigned to users who work in the Occupational Health Unit Employee Health Infection Control can be enrolled in the OOPS EH mail group to receive email messages regarding bloodborne pathogen exposure Users with this menu can access all incidents within their facility The Occupational Health Menu contains these options Create Incident Report Edit Validate Stub Record Employee Bill of Rights Reports Log of Needlestick Incidents Print Incident Report Status Print Report of Incident Summary Incident Reports Display OSHA 300 Log 6 ASISTS GUI V 2 0 User Manual June 2002 ASISTS Menus Safety Menu The Safety Menu is assigned to the safety official at the facility Users with this menu can access all
20. TN Exit 62 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Edit Site Parameter Add Edit Station To edit or add a station press the appropriate button The form shown below 15 used to add a new station or edit an existing station in the Site Parameter file The number of stations that can be added is unlimited The following information can be entered when adding or editing a station in the Edit Site Parameter option Station The station that is selected from the drop down menu to have default information added or the station that is selected for editing OWCP Chargeback Code default chargeback code for the station OWCP Chargeback Suffix The default chargeback code suffix for the station Physician Information The default Physician data for the station The information includes the Physician Name Physician Address Physician City Physician State and Physician Zip Code gt Default Physician Station Information n Station Chargeback Code Chargeback Suffix Physician Name Physician Address Physician City OE Physician Sae Phy E Physician Title Save Cancel June 2002 ASISTS GUI V 2 0 User Manual 63 Option Documentation Edit Site Parameter Delete Station To delete a station select the desired station from the station list and press the Delete button The following confirmation message will be displayed Confirm
21. Worker s Comp Menus CA2s begin with a Report of Incident Certain data elements collected on the Report of Incident are also used on the Notice of Occupational Disease and Claim for Compensation CA 2 The Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures and OWCP tabs comprise the CA 2 Form Each user may see and or access a different set of tabs according to the type of incident and or the type of access the user has For example from the Employee Menu the Case Selection List only displays the user s cases Also the supervisor can only retrieve cases where they are listed as the supervisor or secondary supervisor Required fields are indicated with a double asterisk June 2002 ASISTS GUI V 2 0 User Manual 29 Option Documentation Complete Validate Sign CA2 Employee Data Tab The Employee Data Tab is the main entry edit point for processing CA 2 claims Only the employee and or the workers compensation specialist may enter data on this screen If the employee is incapacitated the workers compensation specialist may electronically sign for the employee via the Electronically Sign for Employee option The supervisor can see the fields on this screen but may only edit the Supervisor or Secondary Supervisor fields To make changes to the data on this screen use the Edit Validate Stub Record menu option Worker s Compensation Validate and Sign CA 2 form Select Clai
22. benefits under the FECA and veterans benefits administered by Veterans Benefits Administration VBA for the same injury illness or death Name ASIST SEMPLOYEE ONE SSN 666 11 1111 Date of Job Related Injury IlIness NOV 22 2004 14 00 Part s of the Body involved in job related injury SINGLE EYE Are you a Veteran Dives Eno If Yes Are you currently receiving veteran benefits for a military connected disability Yes No Do you have a claim for a military connected disability pending Oves No Veteran Benefits Admininistation VBA Number Part s of the body involved in your military claim Condition accepted in your miliary claim was informed of the regulations involved in filing a claim for Workers Compensation and a claim or increase in my VBA benefit for military connected disability If both are approved understand that must make an election between the two benefits and will notify the W orkers Compensation Specialist at my employing facility of what choose Employee Signature ASISTSEMPLOYEE ONE ES Date Employee Signed DEC 07 2004 12 36 40 Workers Comp Specialist Signature CHEN JOY ES Date WC Signed DEC 07 2004 12 39 21 This form will be filed with your claim for workers compensation benefits and with VA Regional Office VBA office 92 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Print Incident Report Status This option can be found on the Su
23. incidents within their facility The Safety Menu contains these options Change Status of Case Create Incident Report Create Amendment Complete Validate Sign Incident Report Edit Site Parameter Employee Bill of Rights Enter Edit Location of Injury Detail Manual Transmission of National Database Data OSHA 300 Options Classify Incident Outcome Enter Edit OSHA 300A Summary Data Display Incident Outcome Report Display Incidence Rates Worksheet Display OSHA 300A Summary Display OSHA 300 Log Reports Log of Federal Occupational Injuries Log of Needlestick Incidents Print Incident Report Status Print Report of Incident Summary Incident Reports Location of Injury Report June 2002 ASISTS GUI V 2 0 User Manual 7 ASISTS Menus Workers Comp Menu The Workers Comp Menu is assigned to workers compensation specialists at the facility Users with this menu can access all incidents within their facility The Workers Comp Menu contains these options Change Status of Case Complete Validate Sign CA1 Complete Validate Sign CA2 Electronically Sign for Employee Employee Bill of Rights Enter Edit Union Information Print Blank CA1 CA2 CA7 Edit Site Parameter Print CA1 CA2 Print CA 7 Print Dual Benefits Form Manual Transmission of DOL Data OSHA 300 Options Display OSHA 300A Summary Display OSHA 300 Log Request for Compensation CA7 Reports Log of Needlestick Incidents Print Incident Report Status Print Report of
24. nnns nnns nsns ese s nsns esas 80 L OG OF NEEDLESTICK INCIDENTS 1 2 teer reco ea eee exte ea deest ee eee rte dee eee ve Poe tea dee dee veter Te ee ed ee ve ae eaa ee 82 MANUAL TRANSMISSION OF DOL rre dea nennen eara eene ae 84 MANUAL TRANSMIT OF NATIONAL DATABASE DATA sisi 85 PRINT BLANK CA T CA2JIG AT eee nn een eoe eee eee ex reete teg eee e e ce eee ee eee E eve Ne Tena EYE 86 PRINT CAT G A2 aet en mit M devas eee ete Pep eee ee Vea De e ETE VENE TENE E RR ne ERN Le 89 PRINT yg EP 90 PRINT DUAL BENEFITS POR eee ce eere terere eee ede veces ede e eee eee Pep eee ey ve Pe te eee eter Tende ee ee ee ae 92 PRINT INCIDENT REPORT STATUS iere nn nes rex ep teg eee der eee Pee ie deep E Te dee e ea vea ae det cie de 93 PRINT REPORT OETINGIDENT eer cen eee ree recor eee ee 95 REASON FOR CONTROVERT REPORT eee texere ree etes ee det deed er eese Tea dee e ea vea ae uada EYE 99 REASON FOR DISPUTE en en dee eet ETE ee Pe cet eee ve Eu Pe ER e CER ae SER e 102 REQUEST FOR COMPENSATION CAT aries an ia kein 104 Sections ESA SR ier uae ee Wag bala Ue e vat 105 Sectionsi3s4 t inne nie OPE PEE eien eise ei 106 SECHOMS 930 TOP tette oU DENT ee Uer D Ne LE 107 SS CCLION AIARA en LR An ut rta tese Po tou CE or Ult aae ter Yea 108 Sections O9 Tuis o
25. on the Supervisor and Safety Menus The Complete Validate Sign Incident Report option allows the supervisor to enter information about an incident It provides the foundation for entering data for the Report of Incident Some data elements collected on the Report of Incident are also used on the Federal Employee s Notice of Traumatic Injury and Claim for Continuation of Pay Compensation CA 1 and the Notice of Occupational Disease and Claim for Compensation CA 2 forms There are seven tabs Employee Data General Setting Other Factors Exposure Equipment OSHA and Signatures that comprise the Incident Form Each user may see and or access a different set of tabs according to the type of incident and or the type of access the user has The supervisor can only retrieve cases where they are listed as the supervisor or secondary supervisor Required fields are indicated with a double asterisk and must be completed before the record can be saved ioi xi Select Claim NENNEN SSN Injury lliness Personnel Status Service Type Incident Employee Data General Setting Other Factors Exposure Equipment OSHA Signatures Cost Center Organization Occupation Grade Step Education Person Involved ES Station Number 7 SENTE EE Date of Birth Type of Incident 1 C Female C Male Time Work Began Hire Date Address Press Button t
26. option they choose to file CAT Request for Compensation Form i ml x Select Claim Claim it Person Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 6 Sections 8 9 Sections 10 13 Sections 14 15 SECTION 1 Employee Portion Name Date of Injury ass OwCPFieit Mailing Address O Email Address City OO Home Phone LEE State Fax 4 Zip Code SECTION 2 gt Compensation is claimed Inclusive Date Range Leave Without Pay 7 Intermittent From Salio C Yes 1 C No 2 Leave Buy Back Other Wage Loss Type Schedule Award C Unknown View Read Only Fields w Sign alidate June 2002 ASISTS GUI V 2 0 User Manual 105 Option Documentation Request for Compensation CA7 Sections 3 4 Tab The Sections 3 4 tab contains outside business work information and questions concerning previous claims and dependent information This tab can be accessed by both the employee and workers compensation representative whe CAT Request for Compensation Form ml x Select Claim Claim Person Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 amp Sections 8 3 Sections 10 13 Sections 14 15 SECTION 3 Have you worked outside your federal job during the period s claimed in Section 2 include salaried self employed commission volunte
27. provides version and CRC Delphi generated identification code information About ASISTS ASISTS 2 0 Automated Safety Incident Surveillance Tracking System Version 2 0 Copyright Department of Veteran Affairs 2002 The prototype for this software was originally developed by the West Palm Beach Medical Center Many thanks are given to the WPB team for their advancement of ASISTS CRC E31FOES87 2 7 1 0 Technical Support The VA Service Desk formerly Help Desk can be reached at 1 888 596 4357 Release Notes To access the Release Notes for current and past ASISTS GUI V 2 0 patches please go to the ASISTS Training page on the VistaU website at http vaww vistau med va gov VistaU asists June 2002 ASISTS GUI V 2 0 User Manual 115 About ASISTS 116 ASISTS GUI V 2 0 User Manual June 2002
28. report date range June 2002 ASISTS GUI V 2 0 User Manual 99 Option Documentation Reason for Controvert Report 100 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Reason for Controvert Report Reason for Controvert Blk 36 Report for 11 19 2010 through 5 18 2011 for Station All Stations 8 of Occurrences Controvert Code 0 a The disability was not caused by a traumatic injury 0 b The employee is a volunteer working without pay or for nominal pay or a member of the office staff of a former President 0 The employee is not a citizen or a resident of the United States or Canada 0 d The injury occurred off the employing agency s premises and the employee was not involved in official off premise duties 0 e The injury was proximately caused by the employee willful misconduct intent to bring about injury or death to self of another person or intoxication 0 f The injury was not reported on Form CA 1 within 30 days following the injury 0 g Work stoppage first occurred 45 days or more following the injury 0 h The employee initially reported the injury after his or her employment was terminated 0 i The employee is enrolled in the Civil Air Patrol Peace Corps Youth Conservation Corps Work Study Programs or other similar groups 0 Controvert question checked Yes but no Controvert Code entered Total 0 June 2002 ASISTS GUI V 2 0 User Manual 101 Option Documentation Reason for Dispute
29. 005 Added Page 1 of 1 54 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Display Incidence Rates Worksheet This option can be found on the Safety Menu under OSHA 300 Options The Calculate Injury and Illness Incidence Rates Worksheet will only include cases where the Include on OSHA Log field equals YES that is OSHA eligible cases The user will be prompted to enter a start date end date and station The specified date range must be for 2004 or greater The selected date range and date time the report was generated will be displayed in the footer of the Injury and IlIness Incidence Rates Worksheet Injury amp Illness Incidence Rates Worksheet SEE Report Run Dates Start Stat Year 2006 End Month Y End Year 2006 Y Station Y Print Print Preview Exit The Incidence Rates Worksheet report will display the following information for the specified date range and station Total Number Of Injuries and Number Of Hours Worked By Employees Total Recordable Case Rate Number Of Entries In Column ColumnI columns on the OSHA 300 Log and DART Incidence Rate June 2002 ASISTS GUI V 2 0 User Manual 55 Option Documentation Display Incidence Rates Worksheet gt SS jury amp Bness Inciderce Rates Worksheet tht Period JAN 2001 throagh OCT 2084 br Staion LOMO BEACH CA ox ageioti 7
30. 02 ASISTS GUI V 2 0 User Manual TT Option Documentation Location of Injury Report Example of Standard Report format 78 Print Preview rn 68 R 1 of 1 Close Type of Incident Assault Cumulative Trauma Cumulative Trauma Cumulative Trauma Cumulative Trauma Cumulative Trauma Environmental Toxic Exposure Environmental Toxic Exposure Latex Reaction Allergy Latex Reaction Allergy Lifting Non Patient Care Lifting Non Patient Care Lifting Repositioning Patients Lifting Repositioning Patients Material Handling Material Handling Not Elsewhere Classified Sharps Exposure Sharps Exposure Slip Trip F all Slip Trip F all Slip Trip F all Slip Trip F all Struck by against Location of Injury Report for 3 22 2005 through 9 18 2005 for Station All Stations Location of Injury Grounds Roads Lots BDC Blood Draw Center BDC Blood Draw Center Food Serice Area CU Intensive Care Unit NO LOC ENTERED LOC ENTERED Pharmacy Areas Cooling plant LOC ENTERED Laundry LOC ENTERED E R Emergency Room O LOC ENTERED Cardiac Cath Lab Dorniciliary ADHC Domiciliary ADHC E R Emergency Room Grounds Roads Lots LOC ENTERED Other Non Patient Care Area Parking lot Public Area Waiting Corridors NO LOC ENTERED Location NO DETAI Detail L ENTERED LALALALALS DETAI DETAI DETAI DETAI reon Sto DETAI DETAI DETAI
31. 2 0 User Manual June 2002 ASISTS Menus Name Search Screen Name Search Screen This screen allows the user to search for an individual who is in the PAID and or ASISTS database June 2002 ASISTS GUI V 2 0 User Manual 11 ASISTS Menus Duplicate Record Screen JupJcals Resort WARNING The Specified Individual Has Potential Duplicate Records lone uhe recurcs beluw uuks like lie une yuu are lu reale please EXI without creating a new record C eate New After the individual has been selected the system will check to see if there is a currently Open case for any person with the same social security number If applicable the above screen is displayed 12 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation The Option Documentation Section contains documentation for all ASISTS software options presented in alphabetical order as listed below In as much as different users may be assigned a variety of options this section provides quick access to any specific option documentation Change Status of Case Classify Incident Outcome Complete Validate Sign CA1 Complete Validate Sign CA2 Complete V alidate Sign Incident Report Create Amendment Create Incident Report Display Incident Outcome Report Display Incidence Rates Worksheet Display OSHA 300 Log Display OSHA 300A Summary Edit Site Parameter Edit Validate Stub Record Electronically Sign for Employee Employee Bill of Rights En
32. 3 he ina er Jos Osta of ia W ers avr t 2 d won set a eom e ws OW C AUTOVATON ASE KOSTER ASA Page Totals Sc Bs D Printed 2 150005 11 13 40 PM 5 44 Ga 4 E i Feport Cate Range 172004 6002004 i a m am mo 9 m Page 1 of 1 eo 60 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Display OSHA 300A Summary This option can be found on the Safety and Workers Comp Menus under OSHA 300 Options The Display OSHA 300A Summary option includes all cases where the Include on OSHA Log field equals YES OSHA eligible cases The OSHA 300A summary information is retrieved and calculated from the data entered in the Enter Edit OSHA 300A Summary Data option the Create Incident Report option and the Complete Validate Sign Incident Report option If a case has more than one classification e g the case begins as a restricted duty then becomes a lost time or days away from work claim the system will only count the most severe classification on the OSHA 300A Summary report A case can only be included once in the summary totals Before the OSHA 300A Summary information can be displayed or printed the user must select the start and end dates along with the station from the drop down list Print Preview DER rn JA WS de OSHAS 300A nev 01201 Year 2 004 Summary of Work Related Injuries amp N
33. E pente riad Occupational Safety aud Maalth Ad mmiatre th Al edad lisim are covered hy 904 mstconpldethis Semmmy page arm Fon injures ov iln esses occured daing t end review thelog k Establishment Information U Thes us etieiinis Seba making sure you Ve aida fie erties fom eveg pageotthelog Fyow ne ALBANY pers Employes vives fave eiii the OSHA Fam 300 nits hi re clined access b the OSHA STREET ADDRESS equivale See CFR Pat 0438 OSHA s raodh coping mle denis on tre access provisions thes MANT ARN ALBANY NY 1226 16 Nunber of Cases Total amubero Toslamaderof To nlamubero fox oe Iotalamaderof NADA casos with days with p V or otliiecenlbb away fo mid tiston cater 0 1 1 0 Bi Of Nunber of Days 5 zr 4 08 3 Total away Toti anubsrofiayy o fob domo we triction Employment information a 4 2332 Injury and IEness Type Sign Total wals rof Eno wnglrfalzifrig d amp documentmoy reuk n fine 2 0 E ngon A 6 2 tind oat 3 G Bapintey conditions 0 296 397 8987 245 2005 page Febraary 1o Apr 30 ofthe year wing the covered by the form 0 Page 1 of 1 June 2002 ASISTS GUI V 2 0 User Manual 61 Option Documentation
34. IDENT REPORT nee eret het teer eret mn annee ane en ne eerte nn te 50 DISPLAY INCIDENT OUTCOME REPOR Tenne 53 DISPLAY INCIDENCE RATES 55 DISPEAY OSITA 300 D OG en recte vv eee deut 58 DISPLAY OSHA 300A SUMMARY eeeceeeee e e e e e emen nnnm enhn nnns nnns nsns uses us use ese ases e a esu e ese a ese esa a tasas esee 61 EDIPSITEPARAMETER eatem qum dio IO IN 62 EDIT V ALIDATE STUB RECORD cccccsceceesescececeevercececscucsceeveececececececceveneseseucveseccvenevesevevecsceveceveveveveseceveceveseveveveseves 65 ELECTRONICALLY SIGN FOR EMPLOYEE cccccccscscscscscecccecececsceceeecscecececececececececscececscecececasasecsescaueseseeaeeeaeeueeaeaeaes 66 EMPLOYEE BILE OF RIGHIS GIO OPINOR cane theses IE eae 68 ENTER EDIT LOCATION OF INJURY DETAIL cccccccccscscsccecececececececececececececececececececesecacececesaceeseaseuaseseususeaseseueeseaes 69 ENTER EDIT OSHA 300A SUMMARY DATA Q ccccccccececscseecececececececececececececscececececscecacecacececeeasacsessasaseuecauseseseeuseaeaes 71 ENTER EDIT UNION INFORMATION ccccccccscecececececececeeececscecececececececececececscacscecasececesecacacecacacacseasauaceeseaeesseeueeeeseaes 73 FILING INSTRUCTIONS 75 LOCATION OF INJURY REPOR Torne TT LOG OF FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES ene e emen n nnn
35. Reason for Controvert Report This option can be found on the Workers Comp Menu under Reports The user is asked to enter a start date end date and either a single station or all stations The report gives a count of the number of each of the following reason for controvert codes for both lost time and no lost time cases The disability was not caused by a traumatic injury The employee is a volunteer working without pay or for nominal pay or a member of the office staff of a former president The employee is not a citizen or resident of the United States or Canada The injury occurred off the employing agencies premises and the employee was not involved in official off premises duty The injury was proximately caused by the employee misconduct intent to bring about injury or death to self or another person or intoxication The injury was not reported on Form CA 1 within 30 days following the injury Work stoppage first occurred 45 days or more following the injury The employee initially reported the injury after his or her employment was terminated The employee is enrolled in the Civil Air Patrol Peace Corps Youth Conservation Corps Work Study Programs or other similar groups Note The last item is NOT a Controvert code but is included to handle those possible scenarios The report will indicate the number of cases in the total count that had data in block 36 State the Reason in Detail and the number of cases not controverted in the
36. Reason for Dispute Report Reason for Dispute Report for 11 19 2010 through 5 18 2011 for Station All Stations Reason for Dispute Code Lost Time Cases No Lost Time Cases A personal emotional reaction to administrative activities 0 0 Different medical opinions about injury weight of evidence 0 0 Different stories about what happened 0 0 Employee did not follow facility policies procedures 0 0 Inappropriate medical provider 0 0 Injury was not work related 0 0 Investigation of incident does not support employee s statement 0 0 Medical diagnosis treatment not related to claimed condition 0 0 No medical evidence to support work related injury 0 0 Timeliness of reporting incident 0 0 Total Cases 0 ww a IE deta in Block 36 Number of Cases not disputed during report date range 0 1 June 2002 ASISTS GUI V 2 0 User Manual 103 Option Documentation Request for Compensation CA7 This option can be found on the Employee and Workers Comp Menus The Request for Compensation CA7 option allows either the employee or worker s compensation personnel to enter information for a request for compensation There are 6 tab sheets on the CA7 Form The first three tabs of the form are accessible by both the employee and worker s compensation personnel the last 3 tabs on the form can only be accessed by workers compensation personnel Selecting the Create CA7 button after you have selected the associated CA claim will initiate and create
37. S 4 22 2008 1 04 20 PM 8241 Yes PERSONNEL ABDOMEN ASISTS GUI V 2 0 User Manual 83 Option Documentation Manual Transmission of DOL Data This option can be found on the Workers Comp Menu The Manual Transmission of DOL Data option provides workers compensation personnel the ability to manually resend CA 1 or CA 2 data that was previously queued to the Austin Automation Center AAC for transmission to the Department of Labor DOL The CA 1 or CA 2 data can be transmitted immediately or queued for future transmission A security key is required to access this option and should be assigned to individuals responsible for sending CA 1 or CA 2 data to the AAC This option should ONLY be used when the transmission to the AAC was corrupt or not completely received This option is NOT designed to retransmit a single case Manual Transmission of DOL Data Seles This Option should not be used unless notification has been received that the claims were not successfully transmitted to the Austin Automation Center Re Transmit Cases for Which Date 14 1 2004 Date to Queue Transmission 14 1 2004 xl Time to Queue Transmission OK Exit 84 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Manual Transmit of National Database Data This option can be found on the Safety Menu The Manual Transmit of National Database Data option provides the safety official the ability to manua
38. TS State TEXAS X Zip Code 75025 Voluntary Sve Phone 555 555 5555 Sec Super SUPERVISOR TWO E gt Print Save June 2002 ASISTS GUI V 2 0 User Manual 65 Option Documentation Electronically Sign for Employee This option can be found on the Workers Compensation Menu The Electronically Sign for Employee option provides a mechanism to allow the workers compensation specialist to sign the Employee portion of a CA1 or CA2 claim This would only be necessary if the employee was incapacitated and unable to sign for themselves Note Obtaining approval from the Occupational Health Unit and safety officer for the workers comp specialist to sign for the employee is no longer required Workers Comp Signing for Employee Select Claim a SSN Injury lliness Personnel Status Service Type Incident Once the case is selected the user is prompted for their electronic signature Enter the electronic signature and press the button to file or press the Cancel button to stop the action Electronic Signature Enter Electronic Signature Code EE Dk Cancel Once the electronic signature is successfully entered a confirmation message will appear 66 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Electronically Sign for Employee If the fields on the employee s portion of the CA 1 or CA 2 are incomplete or missing an error mes
39. To calculate the Total Recordable Case Rate for the specified period the system sums the Total Number of Injury and Illness incidents for that year multiplies the number by 200 000 then divides the number by the Number of Hours Worked By Employees To calculate the DART Incidence Rate for the specified period the system sums the Total Number of Injury and IlIness entries on the OSHA 300 Log that involved days away from work and job transfer restriction multiplies the number by 200 000 then divides the number by the Number of Hours Worked By Employees DEFINITION OF TOTAL RECORDABLE CASE RATE An incidence rate is the number of recordable injuries and illnesses occurring among a given number of full time workers usually 100 full time workers over a given period of time usually one year The system shall compute the Incidence Rate for all recordable cases of injuries and illnesses Total Number of Number of Hours TOTAL RECORDABLE Injuries amp Illnesses X 200 000 Worked by All Employees CASE RATE NOTE To find out the total number of recordable injuries and illnesses that occurred during the year count the number of OSHA eligible cases and sum the entries for Columns I and J on the OSHA 300 Log NOTE The safety official will enter the number of hours worked by all employees on a monthly basis in the Enter Edit OSHA 300A Summary Data option The system will retrieve and use this information in the calculatio
40. User Manual June 2002 Option Documentation Create Amendment Once a selection has been made the following message box will appear automatically Clicking on the Yes button or pressing the Enter key will create the amendment Click on the No button or press the ESC key to cancel the request Confirm Do you want to ammend record 2002 00100 Case Number 2002 001004 has been assigned to this amended incident Use option Complete Validate Sign Accident Report 2162 to complete this case June 2002 ASISTS GUI V 2 0 User Manual 49 Option Documentation Create Incident Report This option can be found on the Supervisor Occupational Health and Safety Menus When an incident occurs causing injury or illness or multiple instances occur over time causing illness a Report of Incident must be created The individual involved goes to his her supervisor Occupational Health Unit safety official or if it is after hours to the Administrative Officer of the Day AOD to report the incident A stub record is created using this menu option The stub record contains basic information related to the incident Required fields are indicated with a double asterisk and must be completed before the record can be saved If Illness is checked on the Incident Information panel Illness Type is prompted for if Injury is checked njury Severity is prompted for amp Create Incident Report 5 xl Personnel Status No
41. Ve Iniu y avilor proper loss Every be mate b ob bin be wua Int alia relaing Io an Iniddeni Tom ober sources shoud he indiddua Inuived rere loprovide be reques Ed Infmallon TASER 100520029 Ome created FeS02 2006401438 Created CHENJO Y Report Fun ine 31222008 mass FM 0 Page 20f3 2 June 2002 ASISTS GUI V 2 0 User Manual 97 Option Documentation Print Report of Incident gt amp OTHER FACTORS SECTION Cauce ofholdent Additonal Cau ce ofinoMent Pre vemtive Metiod orreot Stic Se verty ofin dnoMentwa c anin bry OS HA301 DATA SECTION Date Hred F EB O2 2002 Time Began Work 05 04 Ine Type dnoldentwa can Hne cci nolude On OSHA Log Be ne lcCacea Frivaoy Ca ce Ove Dat of Death FEB O1 2005 In imaton abouttie phy dolan tier Healt Care Pro cdonal Riydlolin chen by Via cindividual Ho ptit d o wrnigirta c anin Fa ent ves Br dual teatdina non v Bnergenoy Room Ove E Hon vA Faolltty Information Faollty Mame Street City che Op code SUP ERVIGO R ASBTS Safety Tite ded Safety Offblal Mone 3334445555 Satt Onfolal Mione Et ABCSSS CASEX2005 00028 DufeCmatd FEB02 2006401436 Created CHENJOY Feport Fun tne 4222008 12 495 1 FM 0 Page 3 of 3 2 98 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation
42. Vista Automated Safety Incident Surveillance Tracking System ASISTS V 2 0 Graphical User Interface GUI User Manual June 2002 Revised June 2011 Department of Veterans Affairs Office of Enterprise Development Management amp Financial Systems Revision History Initiated on 09 02 08 Date Description Patch if applicable Project Manager Technical Writer 09 02 08 Enhancements from Patch OOPS 2 15 Zach Fain Richard Corinne Bailey Privacy Act issues modifications to Muller the CA 7 to meet Department of Labor changes to the form 06 15 11 Maintenance Patch OOPS 2 23 April Scott Tim Dawson Update pages 101 103 regarding the Reason for Controvert Report and the Reason for Dispute Report June 2002 ASISTS GUI V 2 0 User Manual Revision History ii ASISTS GUI V 2 0 User Manual June 2002 Table of Contents INTRODUCTION 1 1 BACKGROUND 55er e E e te A E E E D E 1 GIO E I I UI EI EM 1 REPORTING PROCESS FOR THE INCIDENT REPORT eeeeeeeeeenee ee e e ennemi n ener nnns nn nsese ses ise ese esu a ese e ese ase esas usen 2 REPORTING PROCESS CA 1 CA 2 CLAIMS csscccssssscecsssceceessncecsensececesssecsessusecsenaeeecessecsesaeeecsenaeeecnsesecsesseseesenaeers 3 308 COMPEIANCE A E et en ice due me eta dU ISIN 4 QE ra E E eme emiecamaeenetuedcit erai Er 4 Zl id
43. YES will be printed in this column otherwise NO will be printed Log of Needlestick Incident Report 1 x Report Start Date Ez 42007 x Report End Date 4 18 2008 Station AllStations Single Station r Select Single Station Print Print Preview Exit 82 ASISTS GUI V 2 0 User Manual June 2002 Log of Needlestick Incidents Option Documentation Log of Needlestick Incidents for 10 25 2005 through 4 22 2008 for Station All Stations Case Number Dt ofincident Name Place Where Injury Occured Characterization of Injury Object Causing Injury Injury llln Case Status C Ctr Senice Lost Time Body P art Activity at Time of Injury Model and Brand of Object Causing Injury June 2002 2006 00009 JAN 01 2006 Privacy Case Hollow Bore Needlestick Blister Description lllness Open No INFORM ATION RESOURCES MGMT 2006 00028 MAR 13 2006Privacy Case PSYC Hollow Bore Needlestick Abrasion Scratch Bone chip Description Illness Open 8421 Yes INFORMATION SYSTEMS CENTER BONES OF FACE OTHER S Device in inappropriate place BD BECTON DICKINSON VACUTAINER NEEDLES W ECLIPSE THIS IS THE DESCRIPTION OF THE INCIDENT WHAT HAPPENED AND HOW IT HAPPENED WOULD GO HERE 2006 00028A MAR 14 2006Privacy Case NURS Hollow Bore Needlestick Abrasion Scratch Description THIS IS WHERE THE DESCRIPTION OF INCIDENT GOE
44. a new CA7 claim with some of the fields auto populated The CA7 screen is then displayed with all of the associated tab fields available for editing It is important to remember that the claim will not actually be created saved until you either click Save on the CA7 form or try to exit the form After you have selected a CA claim and have clicked the Create CA7 button a message is displayed that the information for the new CA7 has been populated on the form but the claim will not be created until the information is saved ASISTS 2 0 You are about to create a new CA7 do you wish to continue Select CA for New CA7 Creation Select associated CA claim from the list box TBR Select Claim PER en CA Date Injury7lHIness Person Please select the associated Claim for the CA creation from the above list Create CA Exit ASISTS 2 0 Information For the new CA7 has been populated on the form the claim will not actually be created until you save this information 104 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Request for Compensation CA7 Sections 1 2 Tab The Sections 1 2 tab contains the majority of the employee information such as mailing address Date of Incident OWCP file number This tab can be accessed by both the employee and workers compensation representative Section 2 of this tab involves the reason for filing the CA7 A separate CA7 must be completed by the employee for each
45. ar until the end of Feb of the next year Beginning on March 1 the previous year s information can be viewed but not edited A user can enter edit the safety information and industrial information and save their changes without affecting the OSHA 300A Summary information A user can add or edit the OSHA 300A Summary data for one or more months and view the changes 1 e update the display before saving or canceling the information 72 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Enter Edit Union Information This option can be found on the Workers Comp Menu The Enter Edit Union Information option provides workers compensation personnel the ability to enter or edit union representative information This information is used to determine which union representative shall receive union bulletins when so designated by the employees Union Information Click on Union in the list below then select the Add Edit or Delete button to modify that Union Union Name Union Acronym Add Union Edit Union Delete Union Union Representative Exit OOPS UNION Add Edit Union To add or edit a union press the appropriate button The number of unions that can be added is unlimited Press the Save button to save the changes The following information is displayed on the Union Information screen Union Name This is the formal name of the union Union Acronym This field is the union s a
46. art Date 6 23 2006 Report End Date 10 20 2006 Station AllStations Single Station Single Station zl Print Print Preview June 2002 ASISTS GUI V 2 0 User Manual 75 Option Documentation Filing Instructions Report Filing Instructions No lost time and no medcal expenses No lost time medical expenses incurred Lost time covered by leave LYVOP or COP First aid injury No Data E rtered Total 10 20 2006 2 35 58 AM Filing Instructions 39 Report for 10 1 2006 through 10 20 2006 for Station All Stations Humber of Occurrences 76 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Location of Injury Report This option can be found on the Safety Menu under Reports The Location of Injury Report displays the number of incidents for a user selected date range for all stations or a single station Information provided includes type of incident location of injury location detail and the total number of incidents for each cumulative total is also displayed Output formats include Standard Report or Excel spreadsheet 2 Location of Injury Report Report Start Date 022212006 Report End Date 10 19 2006 Station AllStations Single Station Select Single Station a Output Format Standard Report Excel Spreadsheet Print Print Preview Exit June 20
47. cident Report Status SSN Case Status Yr 31 867 par cal Caz Employee Un Signed Un Signed Safety Officer Workers Comp 53N Case Status XX XX 8001 Open cal Caz Employee Un Signed Un Signed Safety Officer Workers Comp SSH Case Status XX X1 0987 Open cal Caz Employee N Visitor PAID TESTLTE LGFIUE Supervisor Safety Officer Workers Comp ASISTS GUI V 2 0 User Manual for Open amp Clos ed Cases 1 1 2008 through 2 1 2008 for All Stations Date Time of Incident 01 2006 12 01 2162 WCP Un Signed Un Signed Un Signed Date Time of Incident 01 2006 12 01 2162 WCP Un Signed Un Signed Un Signed Date Time of Incident 02 2006 12 02 2162 WCP Un Signed Un Signed June 2002 Option Documentation Print Report of Incident This option can be found on the Supervisor Menu and on the Occupational Health Safety Workers Comp and Union Menus under Reports The Print Report of Incident option provides Occupational Health Unit personnel supervisor safety official union personnel or workers compensation personnel the ability to print a hardcopy of the Report of Incident or view the report on the computer screen inix Select Claim SSSR ANNE SSN Injury lliness Personnel Status Service Type Incident Print Print Preview Exit An example report begins on the following page June 2002 ASISTS GUI V 2 0 User Manual 95 Option Documentation
48. cronym or abbreviation e g AFGE Union Representative Click this button to select the union representative Union Representative Name This field contains the union representative s name for the union It will be used to send the Mailman bulletin if the employee consents to sending information regarding their claim to the union June 2002 ASISTS GUI V 2 0 User Manual 73 Option Documentation Enter Edit Union Information Union Information Click on Union in the list below then select the Add Edit or Delete button to modify that Union Union Name Union Acronym OOPS UNION Add Union Edit Union Delete Union Union Representative Delete Union To delete union select the desired union from the union list and press the Delete button The following confirmation message will be displayed Confirm 5 Delete this Union Information Press Yes to delete the union or No to return to the union form without deleting If Yes is pressed and the union is successfully deleted the following message will display Asists Record Successfully Deleted 74 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Filing Instructions Report This option can be found on the Workers Comp Menu under Reports Use this screen to print or print preview the Filing Instruction Report for a given time frame for a single station or all stations AT Filing Instructions Report Report St
49. dent The Start Date and Incident Outcome Classification are required in order to add an entry In order to add a second or subsequent entry an end date must be entered for the previous entry Edit Incident If an end date is not entered for the last incident outcome entry it can be edited by clicking the edit button Delete Incident If an end date is entered for the last incident outcome entry the entry can be deleted June 2002 ASISTS GUI V 2 0 User Manual 17 Option Documentation Complete Validate Sign CA1 This option can be found on the Employee Supervisor and Worker s Comp Menus All CA 1s begin with an Incident Report The Complete Validate Sign CA1 option allows the supervisor to complete information on the Supervisor s Report of the CA 1 Certain data elements collected on the Incident Report are also used on the Federal Employee s Notice of Traumatic Injury and Claim for Continuation of Pay Compensation CA 1 and the Notice of Occupational Disease and Claim for Compensation CA 2 The Employee Data Injury Witness Data Agency Work Schedule Third Party Physician Filing Instructions and OWCP tabs comprise the CA 1 Form Each user may see and or access a different set of tabs according to the type of incident and or the type of access the user has For example from the Employee Menu the Case Selection List only displays the user s cases Also the supervisor can only retrieve cases where they are listed as the s
50. e and workers compensation personnel indicating that this claim is not a claim covered by another military claim When the employee selects the Complete Validate Sign CA 2 option Are you a Veteran is displayed as a popup message If the response is NO the CA2 form will be displayed If the response is YES the Dual Benefits form will be displayed for the user to complete If the user responds Yes to Do you refuse to answer the Dual Benefits questions on this form they will not be required to respond to the dual benefits questions and can save and exit the Dual Benefits form to get to the CA form If the user responds NO the user can answer the dual benefit questions and sign the Dual Benefit form prior to accessing the CA form The employee will not have to sign the Dual Benefits form prior to signing the CA form The Dual Benefits form will be kept in the employee s workers compensation file that is maintained by the facility It is not transmitted to the DOL It will be sent to the local VA Regional VBA Office for veteran employees filing an OWCP claim for injuries involving those for which they are service connected and receiving compensation and pension funds from the Department of Veterans Affairs 38 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 gt Dual Benefit Questionnaire PREVENTION OF DUAL BENEFITS FOR JOB RELATED INJURY ILLNESS The Federal Employees Compensation Act
51. e case is no longer available for edit because the supervisor or employee has signed it Only cases with the case status of Open can be selected The original case record is duplicated and all signatures are removed The original case status is changed to Replaced by Amendment The case number references the duplicate case with an alpha character added to the end For example case 2002 00100 will be copied into case 2002 00100A and all electronic signatures will be removed The original date time of occurrence cannot be changed using an amendment If the original date time of occurrence is incorrect use the Change Status of Case option to change the case status to Deleted and create a new case with the correct date time of occurrence After the new record has been created the case may be corrected using one or more of the following options Edit Validate Stub Record Complete Validate Sign Incident Report Complete Validate Sign CA1 or Complete Validate Sign CA2 NOTE After a claim is successfully transmitted and accepted at DOL an amendment should NOT be retransmitted to DOL even to correct information on the claim The facility will need to submit the change request via hardcopy gt Create Amendment 15 Select Chin NE SSN Injury lliness Personnel Status Service Type Incident Create Amendment Exit The user must select a claim and click the Create Amendment button to initiate the process 48 ASISTS GUI V 2 0
52. eas Employing Agency Supervisor or Compensation Specialist Complete shaded boxes a b and c Employee Data 1 Name of Employee Last First Middle ASISTSEMPLOYEE ONE 3 Date of Birth Mo Day Yr 4 Sex 5 Home telephone JAN 11 1951 Male 123 123 1234 7 Employee s home mailing address including city state and zip code 1111 ASISTS AVE ALBANY NEW YORK 12210 2 Social Security Number 666 11 1111 6 Grade as of date of last exposure Level 12 Step 6 8 Dependents C Wife Husband Children under 18 years Other 10 Location address where you worked when disease or illness occurred Include city state and ZIP code 11 Date you first became aware of disease or lliness Mo Day Yr Claim Information 9 Employee s Occupation 13 Explain the relationship to your employment and why you came to this realiz ation 12 Date you first realized the disease or illness Mo Day Yr was caused or aggravated by your employment 14 Nature of disease or illness OWCP Use NOI Code DERS 15 If this notice and claim was not filed with the employing agency within 30 days after date shown above in item 12 explain the reason for the delay 0 Page 1 of 4 June 2002 ASISTS GUI V 2 0 User Manual 89 Option Documentation Print CA7 This option can be found on the Workers Comp Menu Type in a Name or SSN do not use DASHES
53. ed by Veterans Benefits Administration for the same injury or death Name SISTS EMPLOYEE TWENTYT SSN 666 06 6623 Date of Job Related Injury JUL 30 2008 06 30 Part s of the body involved in job related injury Do you refuse to answer the Dual Benefits questions on this form C Yes C No Are you currently receiving veteran benefits for a military connected disability C ISIN Do you have a claim for military connected disability benefits pending C Yes i C Nol Veteran Benefits Admin Number of body involved in your military claim Condition accepted in your military claim was informed of the regulations involved in filing a claim for Workers Compensation and a claim or increase my VBA benefit for military connected disability If both are approved understand that must make an election between the two benefits and will notify the workers Compensation Specialist at my employing facility of what choose Employee Signature Date Signed Workers Comp Specialist Signature Date Signed This form will be filed in your claim for workers compensation benefits and with VA Regional Office VBA office If you have any questions regarding this form please contact your Worker s Compensation Specialist Sign Validate 28 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 This option can be found on the Employee Supervisor and
54. elects the Complete Validate Sign CA 1 option Are you a Veteran is displayed as a popup message If the response is NO the CA1 form will be displayed If the response is YES the Dual Benefits form will be displayed for the user to complete If the user responds Yes to Do you refuse to answer the Dual Benefits questions on this form they will not be required to respond to the dual benefits questions and can save and exit the Dual Benefits form to get to the CA form If the user responds NO the user can answer the dual benefit questions and sign the Dual Benefit form prior to accessing the CA form The employee will not have to sign the Dual Benefits form prior to signing the CA form The Dual Benefits form will be kept in the employee s workers compensation file that is maintained by the facility It is not transmitted to the DOL It will be sent to the local VA Regional VBA Office for veteran employees filing an OWCP claim for injuries involving those for which they are service connected and receiving compensation and pension funds from the Department of Veterans Affairs June 2002 ASISTS GUI V 2 0 User Manual 27 Option Documentation Complete Validate Sign CA1 Dual Benefit Questionnaire 10 PREVENTION OF DUAL BENEFITS FORA JOB RELATED INJURY ILLNESS The Federal Employees Compensation Act FECA Seciton 8116 prohibits an employee from receiving workers compensation under the FECA and veterans benefits administer
55. enu option Two mailman messages will be sent to the OOPS WCP mail group when claims successfully process in ASISTS and transmit to the Dept of Labor via the Austin Automation Center AAC Data elements are extracted and transmitted from the ASISTS package to the AAC In order for a case to be transmitted it must have a Closed status Members of the OOPS NDB MESSAGES mail group should be individuals who need to be notified of error messages or return messages from the AAC The group must have at least one member for data to be transmitted to AAC The date that a record is transmitted to the AAC is automatically recorded in ASISTS Once the record is transmitted it is no longer editable from ASISTS ASISTS will not receive data back from the AAC The option Scheduled Transmit National Database 2162 Data OOPS SCHEDULED XMIT 2162 DATA should be scheduled to run on a weekly basis during off peak hours Error checking is preformed to assure that the system is set up as required for mailing the mail messages and that the mail messages are created correctly If an error occurs a message will be sent to the mail group OOPS NDB MESSAGES advising of the problem June 2002 ASISTS GUI V 2 0 User Manual 3 Introduction 508 Compliance Throughout the ASISTS application if the software detects an active screen reader is being used additional text is displayed to the user welcoming them to the system and instructing them on how to use the menu op
56. er etc Yes 1 No 2 Outside Business Information Name OS Type of Work Address Start Date siwy End Date State fo Zip Code I SECTION 4 2 x Mls this the first C4 claim for compensation you have filed for this injury 7 Yes 3 Has there been a change in your dependents or has your direct deposit information changed or has 1 there been a claim filed with U S Civil Service Retirement another federal retirement or disability law or Yes 5 No 6 with the Department of Veterans Affairs since your last C4 claim VECTORS IUE Prev Next MW Sign Validate 106 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Request for Compensation CA7 Sections 5 6 Tab The Sections 5 6 tab contains dependent support payments and questions concerning previous disability claims and annuity information This tab can be accessed by both the employee and workers compensation representative whe CAT Request for Compensation Form Select Claim Claim Person Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 6 Sections 8 9 Sections 10 13 Sections 14 15 SECTION 5 List your dependents including spouse mpm Vah TA Yes 1 C MNo 2 SSN Relationship Date of Birth x Are you making support payments for any of the dependents not living wit
57. ges income sales commissions piecework or payment of any kind during the period s claimed in Section 2 Include self employment involvement in business enterprises as well as service with the military forces Fraudulent concealment of employment or failure to report income may result in forfeiture of compensation benefits and or criminal prosecution Have you worked outside your federal job for the period s claimed in Section Name and Address of Business L ves LI Name Address City State ZIP Code oto Section 4 Dates Worked Type of Work SECTION 4 Is this the first CA 7 claim for compensation you have filed for this injury ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Print CA1 CA2 This option can be found on the Supervisor and Workers Comp Menus The Print CA1 CA2 option provides personnel the capability to view on a computer screen or print a hardcopy of the CA1 or CA2 form for an individual This option also serves as a means to view print a list of open cases noting the presence or lack of electronic signatures Print CA1 CA2 Select Claim SSN Injury lliness Personnel Status Service Type Incident i Print Preview ME DER gt JA WS Notice of Occupational Disease U S Department of Labor and Claim for Compensation Employment Standards Administration D Office of Workers Compensation Programs Employee Please complete all boxes 1 18 below Do not complete shaded ar
58. h you Add E dit Delete amp Yes 3 No 4 i M Support Payments are made to 1 Name Address EEN A Be 4 Court Ordered support payments State Zip Code C Yes 5 8 SECTION Have you ever applied for or received disability benefits from the Department of Veterans Affairs Yes 2 there be a claim made against a 3rd party C Yes 9 Nol Claim Number Nature of Disability Name of V Office Where Claim was filed Office Address Office City Office State Office Zip Monthly Payment lt Have vou applied for or received payment under any Federal Retirement or Disability 1 Eo XOT Asa a na Tice Claim Number Date Annuity Began Amount of Monthly Payment Retirement System xy Prev Next gem MW Sign Validate June 2002 ASISTS GUI V 2 0 User Manual 107 Option Documentation Request for Compensation CA7 Section 7 Section 7 1s the Election of Benefits Statement This is a statement signed by the employee to certify that he she has been truthful on the CA 7 form There is not a Section 7 tab displayed in this option because there is no data for the user to input This statement is printed when the user elects to print the CA 7 form I hereby make claim for compensation because of the injury sustained by me while in the performance of my duty for the United Sta
59. he initial stub record is created and a case number is assigned the supervisor safety official or workers compensation personnel gathers information about the incident counsels the employee to complete a CA 1 or CA 2 and completes the Report of Incident using the Complete Validate Sign Incident Report menu option Once the supervisor electronically signs the case a bulletin is triggered to inform the safety official that the Report of Incident can be reviewed The employee does not need to wait until the Report of Incident is completed to begin the claim process and may choose to initiate a claim for compensation by using the menu options Complete Validate Sign CA 1 for an injury or the Complete Validate Sign CA 2 for an illness The safety official reviews the Report of Incident using the Complete Validate Sign Incident Report menu option and completes the safety official related questions and comments on the Signatures Tab The case should remain open until it is successfully sent to the Dept of Labor or when the reporting process is complete 2 ASISTS GUI V 2 0 User Manual June 2002 Introduction Reporting Process CA 1 CA 2 Claims The employee enters data for the CA 1 or CA 2 using the Complete Validate Sign 1 option for injury and Complete Validate Sign CA 2 option for illness When the employee signs their portion of the CA 1 or CA 2 this triggers a bulletin to the supervisor union representatives and workers compensation
60. i m 11 27 2001 80 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Log of Federal Occupational Injuries and Illnesses amp ARTE Wiens Ada b ta n Qin mW onc Am b tal Log of Federal Oco pellianel rues end Ens ss0s S LAO 1 FEROS 78 Cuties G3hef Ema e VES CONTERC TOG TED TO Bay ain E Fage 1 of June 2002 ASISTS GUI V 2 0 User Manual 81 Option Documentation Log of Needlestick Incidents This option can be found on the Occupational Health Safety and Workers Comp Menus under Reports This option prints the Log of Needlestick Incidents report This report compiles data from the Report of Incident when the Type of Incident 15 a Hollow Bore Needlestick Sharps Exposure Exposure to Body Fluids Splash or a Suture Needlestick Before the report can be displayed or printed the user must select the start and end dates along with the station The report can be run for all stations or a single station If all stations 1s selected the report is not sorted by station The words Privacy Case will print in place of the name for every case on this report The Lost Time column has been added back into this report If the response to the Initial Return to Work Status is Days Away Work then
61. ident f Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OWCP Regular Work Hours From Y Regular Work Hours To Y m Regular Work Schedule Check the days of the week worked when the Incident occured Sunday Monday Tuesday Wednesday Thursday Friday Saturday Dates Times Date Employee First reported Condition to Supervisor Date Time Employee Stopped work Date Time Employee Pay Stopped Date Employee was Last Exposed to conditions that are alleged to have caused Disease or Illness Date Time Returned to Work If Employee has returned to Work and Work Assignment has Changed Describe Employee s New Duties lt Prev Next gt June 2002 ASISTS GUI V 2 0 User Manual 33 Option Documentation Complete Validate Sign CA2 Third Party Tab Information pertaining to third party and incident specific questions 15 located on this tab x Worker s Compensation Validate and Sign CA 2 form Select Claim EER SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OWCP Was Illness Caused by third Party Do not Include Patient or Employee Yes 1 No 2 Name and Address of Third Party Name Street City State Zip xu Prev Next gt
62. intermittent complete Form CA 7a d Schedule Award Go to Section 4 Time Analysis Sheet SECTION You must report all earnings from employment outside your federal job include any employment for which you received a salary wages income sales commissions piecework or payment of any kind during the period s claimed in Section 2 Include self employment involvement in business enterprises as well as service with the military forces Fraudulent concealment of employment or failure to report income may result in forfeiture of compensation benefits and or criminal prosecution Have you worked outside your federal job for the period s claimed in Section Name and Address of Business Yes No Name Address City State ZIP Code oto Section 4 Dates Worked Type of Work SECTION 4 Is this the first CA claim for compensation you have filed for this injury June 2002 ASISTS GUI V 2 0 User Manual 9 Option Documentation Print Dual Benefits Form This option can be found on the Workers Comp Menu Use this screen to select the claim for which you wish to print the Dual Benefits Form You can print the report to your Window s default printer or display the report to the computer screen Print Dual Benefit Form PREVENTION OF DUAL BENEFITS FOR JOB RELATED INJURY ILLNESS The Federal Employees Compensation Act FECA Section 8115 prohibits an employee from receiving workers compensation
63. it Location of Injury Detail DAYTON 552 Engneernashe Metal Shop 70 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Enter Edit OSHA 300A Summary Data This option can be found on the Safety Menu under OSHA 300 Options The Enter Edit OSHA 300A Summary option allows the safety official to enter station specific safety and industrial information in addition to month year specific OSHA 300 information The safety official chooses the station selection from a list box AII the station entries that have been entered through the Edit Site Parameter option will be displayed as valid selections for the station wi Enter Edit OSHA 300A Summary Data DAR Station Information Station Safety Official SUPERVISOR ASISTS RARES SES Safety Official Tite 7 Safety Phone Number 555 555 5555 Safety Phone Ext Industrial Information m Industry Description Skilled Nursind Std Industrial Class 51 8051 Skilled Nursing Care Facilities X Save N A Industrial Class NAICS 621340 Offices of Phy Occ Speech Therapists amp Audiok ES OSHA 3004 Summary Data 5 Month 7 Month Year Avg of Emp Tot Hrs Wked VE C Wa 8888 180000 C C Jun C Jul 777222 77000000 C Sep C Oct Nov 666111 660000 Data for Month Y ear 555121 5500000 Avg Num of Emp 444555 4400000 Tot Hrs Emp Worked Add Edit Save Cancel
64. l Handling Material Handling Not Elsewhere Classified Sharps Exposure Sharps Exposure NO LOC ENTERED E R Emergency Room NO LOC ENTERED Cardiac Cath Lab Domiciliary ADHC Domiciliary ADHC E R Emergency Room Grounds Roads Lots NO DETAIL ENTERED NO DETAIL ENTERED DETAIL ENTERED Dom Room 14 DETAIL ENTERED DETAIL ENTERED Slip Trip F all NO LOC ENTERED Slip Trip F all Other Non Patient Care Area NO DETAIL ENTERED Slip Trip F all Parking lot LEVEL THREE Slip Trip F all Public Area Waiting Corridors DETAIL ENTERED Struck by against NO LOC ENTERED Total MN Sheet1 Sheet Sheet3 Ready June 2002 ASISTS GUI V 2 0 User Manual 14 n e 79 Option Documentation Log of Federal Occupational Injuries and Illnesses This option can be found on the Safety and Union Menus under Reports The option prints the Log of Federal Occupational Injuries and Illnesses Logs can be printed for a date range determined by when the record was first created Date Time of Occurrence This report compiles data from the Report of Incident where the Include on OSHA Log field equals YES The log prints the Case Number Date of Occurrence Name Pay Plan and Occupation Code Department Type of Incident and Body Part Affected It also indicates with an X whether the claim resulted in a fatality lost time or no lost time for both injuries and illnesses
65. led with the employing agency within thirty days explain the reason for the delay below If a separate narrative statement is not submitted with this form explain the reason for delay If medical reports are not submitted with this form explain the reason for the delay Prev Next gt Validate June 2002 ASISTS GUI V 2 0 User Manual 31 Option Documentation Complete Validate Sign CA2 Agency Tab Duty station agency and additional employee information 15 located here Worker s Compensation Validate and Sign CA 2 form Select Claim Signa aS eR SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OwCP Employee Duty Station r Agency Duty Station fo Name Street Po Street City 1 City 3 7 State x State xj Zip Employee Data Continued Cost Center Org Employee s Retirement y Prev Next gt 32 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 Work Schedule Tab Information pertaining to work hours and schedule along with incident dates times are contained here Worker s Compensation Validate and Sign CA 2 form Select Coin EERE SARA SSN Injury IIIness Personnel Status Service Type Inc
66. ll be collected in a national database to identify national trends training needs and best practices for the benefit of all employees at every VA medical center e Reduce worker compensation costs ASISTS facilitates a case management approach to preventing future incidents and provides better management of workers compensation claims Through automation the incident reporting process will be more accurate and be processed in a more timely fashion Reporting Process for the Incident Report When an incident occurs causing injury or illness or multiple instances occur over time causing illness a Report of Incident must be created The individual involved goes to his her supervisor Occupational Health Unit safety official or 1f it is after hours to the Administrative Officer of the Day AOD to report the incident A stub record on the incident is created using the option Create Incident Report The stub record contains basic information related to the incident A bulletin called the Employee Bill of Rights is sent to the employee explaining his her rights and entitlements to benefits following a work related injury or illness The safety official supervisor union representatives and workers compensation personnel receive a bulletin informing them that an incident occurred If it happens to be a bodily fluid exposure Infection Control where applicable and Occupational Health are also notified so they may plan follow up care Once t
67. lly resend incident data that was previously queued to the Austin Automation Center AAC for transmission to the ASISTS National Database NDB The data can be transmitted immediately or queued for future transmission Data is extracted from incident reports to provide statistical reporting on safety incidents that occur at facilities nationwide Reports will be periodically generated from the NDB to identify safety incident trends and to support prevention programs for health care workers exposure to bloodborne pathogens The data collected from the Report of Incident should be transmitted to the ASISTS National Database NDB on a daily basis This option should ONLY be used when the transmission to the AAC was corrupt or not completely received This option is NOT designed to retransmit a single case Manual Transmission of Data ME This Option should not be used unless notification has been received that the claims were not successfully transmitted to the Austin Automation Center Re Transmit Cases for Which Date 14 1 2005 x Date to Queue Transmission 14 1 2004 Time to Queue Transmission OK Exit June 2002 ASISTS GUI V 2 0 User Manual 85 Option Documentation Print Blank CA1 CA2 CA7 This option can be found on the Workers Comp Menu The Print Blank CA1 CA2 CA7 option provides workers comp personnel the ability to print a blank CA1 CA2 or CA7 form should there be a need to fill one out ma
68. m emasa aaeanoa SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OWCP Employee Data 7 ness Information Name Employee s Occupation SSN Cause of Injury Code v Date of Birth Location at Time of Illness Sex C Female C Male Uh ll Street Address 7 Home Phone Lie Grade Step City Home Address sc HH City Zip Code State Zip Code Supervisor Dependents zl Secondary Supervisor 30 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 Claim Information Tab Information pertaining to the dates of disease or illness nature of disease or illness and reasons for delay is located on this tab Worker s Compensation Validate and Sign CA 2 form me ne SSN Injury IIIness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Patty Physician Signatures OwCP Date you first became aware of the disease or illness Date you first realized the disease or illness was caused or aggravated by your employment Explain the relationship to your employment and why you came to this realization Nature of Disease or Illness If this notice and claim was not fi
69. n Documentation Complete Validate Sign Incident Report OSHA Tab The OSHA tab displays information pertaining to data entry for the OSHA 300 log Safety Officer Incident Report 46 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign Incident Report Signatures Tab The Signatures tab displays both the supervisor and safety officials signature information When the Report of Incident is signed the name and date will appear The supervisor must enter corrective action information and the safety official must enter safety comments on this tab wis Safety Officer Incident Report E ni xj Select Coin aa SSN Injury lliness Personnel Status Service Type Incident Employee Data General Setting Dther Factors Exposure Equipment OSHA Signatures C Full duty Job Transfer Restriction Initial return to work status r Days away work not including day of injury Corrective Action No personal identifiers should be used Signed by Supervisor Unsigned Date Signed dt signed Safety Comments No personal identifiers should be used Signed by Safety Officer Unsigned Date Signed dt signed Sign Validate Nest me June 2002 ASISTS GUI V 2 0 User Manual 47 Option Documentation Create Amendment This option can be found on the Safety Menu The Create Amendment option should be used to correct an ASISTS case when th
70. nal code of the individual Summarizes the number of incidents grouped by the Characterization of Injury field Summarizes the number of incidents grouped by the service of the individual Summarizes the number of incidents grouped by major body part Summarizes the number of incidents grouped by each day of the week the incident occurred Groups each incident by hour and summarizes the number of incidents within those time periods The different output formats include Standard Report Excel Spreadsheet Pie Chart and Bar Graph The pie chart and bar graph formats print in the landscape orientation 112 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Summary Incident Reports wie Report Selection Type of Incidents Bi 2 3 2008 z Example of Standard Report Output Format Type of Incidents Report From 2 3 2008 Ta 8 1 2008 For Open amp Closed Cases All Station s All Cases Lost Time No Lost Time Incidents Includes Per Status All Status Type af Incidents Number of Incidents of Total Assault 4 44 44 Environmental Toxic Exposure 1 1111 Hollow Bare Needlestick 1 11 11 ot Elsewhere Classified 1 11 11 Slip Trip Fall 2 22 22 Total g 99 99 June 2002 ASISTS 2 0 User Manual 113 Option Documentation 114 ASISTS GUI V 2 0 User Manual June 2002 About ASISTS This screen acknowledges the West Palm Beach programming staff for their contribution to the ASISTS software It also
71. ne 2002 ASISTS GUI V 2 0 User Manual 19 Option Documentation Complete Validate Sign CA1 Injury Witness Data Tab Miscellaneous injury data along with all the witness information is contained on this tab a Worker s Compensation Edit Employee CA 1 Form Select Claim HENESSOXISEEREEAENMPEOECHUNEGEINENURESEEEIERIEUEN SSN Injury liness Personnel Status Service Type Incident Employee Data Iniury Witness Data Agency Work Schedule Third Party Physician Filing Instructions D WCP Injury Data Employee s Occupation Date Time Injury Occurred Cause of Injury Code Cause of iia Identify both the injury and the part of the body e g fracture of left leg Mature of Injury Witness Name ID 5 y Click on a name in the list to edit or delete Street RE cyl State Zip Date Signed hdd Witness Edit Witness Delete witness x Prev Next gt Sian Validate 20 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA1 Agency Tab Duty station agency and additional employee information are contained on this tab June 2002 ASISTS GUI V 2 0 User Manual 21 Option Documentation Complete Validate Sign CA1 Work Schedule Tab Information pertaining to an individual s work hours work schedule incident dates times and pay rate are on this tab Worker s Compensation Edit Employee CA
72. ne Selected C Resident Physician C Employee C Medical Student C Volunteer C Nursing Student Contractor Other Student Visitor C Other C Non Paid Employee Incident Information m Injury Illness C Injury Illness Illness Time Work Began v Date Time of Injury Type of Incident Y is Station Person Involved Press to Get a New or Employee Name po x Female C Male SSN Address Steet B 7 ss sae VP e Code i i 1 Press a button to select a supervisor Supervisor Secondary Supervisor Supervisor Secondary Super Quick OSHA Log Assessment QOLA Was there Loss of Consciousness None Selected C Yes 1 C No 2 Was prescription strength medication ordered given 4 None Selected C No 8 C Yes 7 C Unknown Hospitalized overnight as in patient None Selected C Yes 3 No 4 Was non Rx medication ordered given at Rx strength None Selected C Now C Yes v C Unknown x Treated in non V4 Emergency Room None Selected Yes 5 C No 6 Initial return to work status None Selected C Full duty Days away work not including day of injury C Job Transfer Restriction E Save Exit 50 ASISTS GUI V 2 0 User
73. ns for the Injury and Illness Incidence Rates Worksheet 56 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Display Incidence Rates Worksheet DEFINITION OF DART INCIDENCE RATE System will compute the incidence rate for OSHA eligible cases involving days away from work days of restricted work activity or job transfer DART Number of Entries in Number of Hours DART Column ColumnI X 200 000 Worked by All Employees Incidence Rate NOTE Column H Days Away from Work and Column I Job Transfer Restriction on the OSHA 300 form June 2002 ASISTS GUI V 2 0 User Manual 57 Option Documentation Display OSHA 300 Log This option can be found on the Occupational Health Menu and Union Menu under Reports and on the Safety and Workers Comp Menus under OSHA 300 Options Before the OSHA 300 Log can be displayed or printed the user must select the start and end dates along with the station from the drop down list The user must also indicate whether or not to include individuals names on the OSHA 300 Log including names is not available if option is selected from the Union Menu If names are included and an OSHA eligible case has been marked as a privacy case in the Complete Validate Sign Incident Report option the name field will display the words Privacy Case in the OSHA 300 Log Additionally if the Type of Incident for a claim is Hollow Bore Needlestick Sharps Exposure Exposure to Body Fluids Splash or Sutu
74. nually Print Blank CA1 CA2 or CA7 Select Blank Form to be Printed C 1 2 C CA Blank CA1 Print Preview BSS n gt S8 G cose Federal Employee s Notice of U S Department of Labor Traumatic Iniury and Claim for Employment Standards Administration Continuation of Pay Compensation Office of Workers Compensation Programs Employee Please complete all boxes 1 15 below Do not complete shaded areas Witness Complete bottom section 16 Employing Agency Supervisor or Compensation Specialist Complete shaded boxes a b and c 1 Name of Employee Last First Middle 2 Social Security Number 3 Date of Birth Mo Day Yr 5 Home telephone 6 Grade as of date 7 Employee s home mailing address including city state and zip code 8 Dependents Wife Husband C Children under 18 years C Other 9 Place where injury occurred e g 2nd floor Main Post Office Bldg 12th amp Pine 10 Date injury occurred 11 Date of this notice 12 Employee s occupation Mo Day Yr Mo Day Yr 13 Cause of injury Describe what happened and why Occupation code i zs IOWCP Use NOI Code Employee Signature 15 I certify under penalty of law that the injury described above was sustained in performance of duty as an employee of the United States Government and that it was not caused by my willful misconduct intent to injure myself or another person nor by my intoxication
75. o Select Supervisor mms Supervisor Secondary Supervisor _Seconday Supervisor State Zip Code Swevsor Phone Ig Sec Super m Prev Print Sign Validate 40 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign Incident Report Employee Data Tab The supervisor can see the fields on this tab but may only edit the Supervisor or Secondary Supervisor fields To make changes to the data on this screen use the Edit Validate Stub Record menu option os Safety Officer Incident Report E 10 xl June 2002 ASISTS GUI V 2 0 User Manual 41 Option Documentation Complete Validate Sign Incident Report General Setting Tab Information relating to the general setting location of the incident is collected in the General Setting tab Safety Officer Incident Report 42 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign Incident Report Other Factors Tab This tab contains information concerning the environmental and contributing factors leading to the incident It also contains the Description of Incident which was previously on the General Settings tab The six dropdown box fields must be answered before the supervisor can electronically sign the form wis Safety Officer Incident Report m oi xj Selec
76. o this realiz ation the disease or illness Mo Day Yr was caused or aggravated by your employment 14 Nature of disease or illness OWCP Use HOI Code um 15 If this notice and claim was not filed with the employing agency within 30 days after date shown above in 12 explain the reason for the delay 0 Page 1 of 4 June 2002 ASISTS GUI V 2 0 User Manual 87 Option Documentation Print Blank CA1 CA2 CA7 Blank CA7 88 Claim for Compensation U S Department of Labor Employment Standards Administration Office of Workers Compensation Programs SECTION 1 EMPLOYEE PORTION a Name of Employee Last First Middle OMB No 1215 0103 Expires 10 31 2008 b Mailing Address fred Cite State OF Cade c OWCP File Number d Date of Injury e Social Security Number E Mail Address Month Day Year SECTION 2 Compensation is claimed for f Telephone No FAX No Inclusive Date Range From To Intermittent a Leave without Pay L ves No Go fo Section S b Leave buy back L Yes CIN Gate Section 2 and Complete Fom CI h Other wage loss specify type Yes Mo Section F such as downgrade loss of 1 1 night ditterential etc Type If intermittent complete Form CA 7a d Schedule Award Go to Section 4 Time Analysis Sheet SECTION You must report all eamings from employment outside your federal job include any employment for which you received a salary wa
77. orming routine tasks that occur more than once a week or is transferred to another position because of the work related incident e Away From Work This classification equates to any day after the date of injury that the employee is not at work e Death This classification is selected when the incident results in a fatality and will require a date of death to be entered Date of Classification Includes the Start Date and End Date e Start Date The start date cannot be a future date and cannot be on or before the previous entry s end date e End Date This end date cannot precede the start date and cannot be a future date Date of Death If the incident outcome classification is Death then the Date of Death is required Estimated Return Date must be future date The estimated return date is not used in any OSHA 300 Log calculations and it does not default from one outcome classification entry to the next 16 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Classify Incident Outcome Classify Incident Outcome Select Claim SSN Injury Iliness Personnel Status Service Type Incident Incident Classification on File Initial Classification Other Recordable Classifications Away from Work Classification Start Date Estimated Return Date Job Transfer Restriction Death Classification End Date Date of Death Save Cancel Print Report Exit Add Inci
78. personnel notifying them of the requirement to complete the form and file with the Department of Labor within 2 3 working days When the supervisor signs the CA 1 or CA 2 using the Complete Validate Sign CA 1 option for injury and Complete Validate Sign CA 2 option for illness a bulletin is sent to the OOPS WCP mail group and also to the supervisor The case remains available to the employee for further editing until the supervisor signs it If the employee retrieves a signed case the electronic signature is removed and the claim must be resigned However once the supervisor signs the case the original case is no longer available for edit by either the employee or the supervisor To edit the claim the safety official or the workers compensation personnel must create an amendment If an employee is incapacitated and cannot electronically sign the claim the workers compensation personnel may sign for the employee via the Electronically Sign for Employee option The workers compensation personnel should use the Complete Validate Sign CA 1 or Complete Validate Sign CA 2 menu option to complete and file the claim with the Dept of Labor The workers compensation personnel should ensure that they have a hard copy of the claim with the employee and the supervisor s wet signature and any witness statements before electronically transmitting the claim to the Dept of Labor A hard copy of the CA 1 or CA 2 can be printed using the Print CA 1 CA 2 m
79. pervisor Menu and on the Occupational Health Safety Workers Comp and Union Menus under Reports The Print Incident Report Status option provides Occupational Health Unit personnel supervisor safety official union personnel or workers compensation personnel the ability to view the Incident Report Status on a computer screen or print a hardcopy This option also serves as means to view print a list of open cases noting the presence or lack of electronic signatures Before the Incident Report Status can be displayed or printed the user must select the start and end dates along with the station The report can be run for all stations or single station If all stations is selected the report is not sorted by station The user must also indicate the case status to be included on the report wi Print Incident Report Status O xl Report Start Date Report End Date 23 2007 5 21 2008 Station All Stations Single Station B Single Station Case Status Both Open and Closed Cases Open Cases Only Closed Cases Only Print Print Preview June 2002 ASISTS GUI V 2 0 User Manual 93 Option Documentation Print Incident Report Status Case Number Name 2005 00001 VOLUNTEER TESTNEXT Case Number Name 2008 00010 PAID OIFO Case Number Name 2008 00002 VISITOR TWO 94 AS ISTSEMPLOYEE ONE Supervisor PAID TESTLFE FOUR Supervisor In
80. r the FEHBP Optional Use Insurance ic Yes 1 No 2 C Yes 2 C No 4 Class Basic Life Insurance Retirement System CYeB CN C Yem Chow Per 2 SECTION 11 Continuation of Pay COP Received Show inclusive dates Intermittent To C Yel No r SECTION 12 Show pay status and inclusive dates for period s claimed at least one entry is required E e Intermittent is s TERT If intermittent Complete Form Intermittent Ie A Annual Leave From es ul C CA 7a Time Analysis Sheet n Intermittent If leave buy back also submit Leave Without Pay From C Yes f C 9 complete Form C 7b Intermittent Work From To C Yes h C SECTION 13 FER RSS 2 Did employee return to work With the same number of hours and duties 1 Yesi C Nok Date C Yesl e Prev Next gt MW Sign Validate 110 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Request for Compensation CA7 Sections 14 15 Tab The Sections 14 15 tab contains the workers compensation remarks and their information including a place to enter a third party that could be contacted for further information on the claim This tab 15 available only to workers compensation personnel 21D x Select Claim Ie Claim Person
81. re Needlestick the words Privacy Case will print as the name if Include Names is Yes Log of Work Related Injuries and Illnesses MODE Enter Report Start Date 10 1 2006 Enter Report End Date 10 20 2006 Station ALBANY 500 Include Names on Report C Yes No Exit 58 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Display OSHA 300 Log For the specified date range and station the system will sum the number of OSHA eligible cases with the following incident outcome classifications and display the total number to the user on the OSHA 300 Log report Death Days Away from Work Job Transfer or Restriction Other Recordable Cases For the specified date range and station the system will sum the number of days that the injured or ill worker was On Job Transfer Restriction or L Away From Work and display this total number to the user on the OSHA 300 Log report When the total number of days for either K On Job Transfer Restriction is equal to or greater than 180 days then the system will display the total number as 180 days OSHA 300 only demands tracking for 180 days The maximum total number of days for column K On Job Transfer Restriction plus column L Away from Work is 180 days The system will sum the total number of OSHA eligible cases with the following illness or injury types and display the total number to the user on the OSHA 300 Log report M1 Injury M2
82. rom facilities and transmitting it to the ASISTS National Database NDB Reports are periodically generated from the NDB to identify systematic trends and to support prevention programs concerning front line health care worker exposure to bloodborne pathogens The ASISTS package provides the capability to electronically transmit CA 1 and CA 2 data to the Department of Labor DOL Federal Law requires that these forms be submitted within 14 days after the employee submits a claim for an accident or illness The data 1s collected at each facility and is then transmitted to DOL via the Austin Automation Center AAC The transmission of each completed form is under the control of workers compensation personnel at each facility Goals ASISTS has three major goals e Better tracking of employee injuries and illnesses ASISTS computerizes the Report of Incident as well as the OWCP CA 1 and CA 2 forms These reports help improve the ability to trend and analyze accidental injuries and illnesses thus helping to prevent future incidents from occurring June 2002 ASISTS GUI V 2 0 User Manual 1 Introduction e Reduce exposures to bloodborne pathogens from needlesticks sharps or body fluids ASISTS instantly notifies Occupational Health and other medical personnel when the employee reports an incident involving a bloodborne pathogen exposure so that proper tests and treatment can be initiated The data concerning exposure to bloodborne pathogens wi
83. s or Canada gJThe injury occurred off the employing agency s premises and the employee was not involved in official off premise duties C The injury was proximately caused by the employees willful misconduct intent to bring about injury or death to self of another person or intoxication C injury was not reported on Form CA 1 within 30 days following the injury g Work stoppage first occurred 45 days or more following the injury C bh The employee initially reported the injury after his or her employment was terminated C i The employee is enrolled in the Civil Air Patrol Peace Corps Youth Conservation Corps Work Study Programs or other similar groups j Unknown Pev Next ge 24 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA1 Filing Instructions Tab Filing instructions and supervisor information such as title and phone number are stored on this tab Worker s Compensation Edit Employee CA 1 Form Select Claim X SSN Injury lliness Personnel Status Service Type Incident Employee Data Injury Witness Data Agency Work Schedule Third Party Physician Filing Instructions owcP Exception and Filing Instructions 3 N E Filing Instructions Supervisor who knowingly certifies to any false statement misrepresentation concealment of fact etc in respect of this claim may also be subjectto appropiate felony criminal prosecution
84. sage will appear with the related fields Use the Complete Validate Sign CA1 or the Complete Validate Sign CA2 option to complete the employee s portion of the claim and resign Electronic Signature The following items MUST be corrected before you can sign this document The following fields must be completed before the can be signed PLACE WHERE INJURY OCCURRED DATE TIME INJURY OCCURRED DATE OF THIS NOTICE lt OCCUPATION June 2002 ASISTS GUI V 2 0 User Manual 67 Option Documentation Employee Bill of Rights This option can be found on all ASISTS menus The Employee Bill of Rights option provides the capability to print a hardcopy of the Employee Bill of Rights or view it on a computer screen The Employee Bill of Rights is sent to the employee notifying them of their rights and entitlements to benefits following a work related injury or illness If an employee does not have computer access and therefore would not receive a message containing the Bill of Rights this option can be used to print a hard copy Employee Bill of Rights BEB ir BSS cs EMPLOYEE BILL OF RIGHTS FOR ACCIDENTS AND OCCUPATIONAL ILLNESSES The Federal Employees Compensation Act FECA describes an employee s rights and entitlements to benefits following a work related injury or illness you have the right to file a CA 1 injury or CA 2 illness to apply for compensation En
85. t Coin aa SSN Injury lliness Personnel Status Service Type Incident Employee Data General Setting Other Factors Exposure Equipment OSHA Signatures Weather Factor m Cause of Incident Source of Incident Additional Cause of Incident Prevention Method Status of Corrective Action When completing the accident narrative the basic questions to consider are What Where When Why and How did the accident happen Describe the activity and any tools equipment or material the employee was using Tell us how the injury occurred What object or substance directly harmed the employee NOTE No personal identifers should be used Description of Incident Sign Validate June 2002 ASISTS GUI V 2 0 User Manual 43 Option Documentation Complete Validate Sign Incident Report Exposure Tab If the Type of Incident selected is Exposure to Body Fluids Needlesticks Sharps Exposure or Hollow Bore Needlestick then the Exposure tab is visible and many of the fields are required os Safety Officer Incident Report 44 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign Incident Report Equipment Tab The Equipment tab captures data specific to any equipment or safety device in use at the time of the incident os Safety Officer Incident Report June 2002 ASISTS GUI V 2 0 User Manual 45 Optio
86. t a duplicate press the Create New Record button 52 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Display Incident Outcome Report This option can be found on the Safety Menu under OSHA 300 Options This report lists all incident outcome entries collected for an individual in the Classify Incident Outcome option Cases that are available for selection search include both Open Closed cases as well as any case that has been electronically transmitted to the National Database or the Department of Labor Deleted and Replaced by Amendment cases cannot be selected Once the claim has been selected the report may be sent to the your default printer or previewed on the computer screen Individual Incident Outcome Listing ee ee ee ere eee __ Pint BirePrevow June 2002 ASISTS GUI V 2 0 User Manual 53 Option Documentation Display Incident Outcome Report BEB Ki gt mn SS Bs cl Display Incident Outcome Report Data for OSHA 300 for Individual ASISTSEMPLOYEE ONE ASISTS Claim No 2005 00031 DaysAway Days Job Estimated Start Date End Date Incident Outcome fromWork Tran Rstr Total RtnDate Last Edited By Last Edit Dt Status 2 10 2005 Aw ay Work 15 3 1 2005 CHEN JOY 2112 2005 Added 2 1 2005 2 8 2005 Job Transfer Restriction 8 15 CHEN JOY 2112 2005 Added 1 25 2005 1 31 2005 Aw ay Work 7 7 CHEN JOY 2112 2005 Added 1 15 2005 1 18 2005 Other Recordable 0 CHEN JOY 2 12 2
87. ter Edit Location of Injury Detail Enter Edit OSHA 300A Summary Data Enter Edit Union Information Filing Instructions Report Location of Injury Report Log of Federal Occupational Injuries and Illnesses Log of Needlestick Incidents Manual Transmission of DOL Data Manual Transmission of National Database Data June 2002 ASISTS GUI V 2 0 User Manual 13 Option Documentation Print Blank CA1 CA2 CA7 Print CA1 CA2 Print CA 7 Print Dual Benefits Form Print Incident Report Status Print Report of Incident Reason for Controvert Report Reason for Dispute Report Request for Compensation CA7 Summary Incident Reports 14 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Change Status of Case This option is found on the Safety and Worker s Comp Menus Only the safety official or the workers compensation specialist has the option to change the status of a case After the case has been selected the Case Status can be changed to Open Closed or Deleted If the status is Deleted the Reason for Deletion is required wie Change Status of a Case Select Claim 1 NOV 22 Z004 14 00 ASISTSEMPLOYEE ONE SSN 666 11 1111 Injury liness Injury Personnel Status Employee Service NURSING Type Incident Exposure to Body Fluids Splash Case Status Open xl Reason for Deletion Save Exit NOTE Closing deleting replacing record by amendment removes it from all selection lists except for print options J
88. tes I certify that the information provided above is true and accurate to the best of my knowledge and belief Official statement made by the employee that the information they wrote on this CA 7 form is the truth as it is against the law to make any false statements or hide information to get money from OWCP Employee s Electronic Signature Date The employee must print out the CA 7 sign it in blue ink then give the original to the Workers Compensation office at their facility on the same day they sign it The employee should also keep a copy for their records 108 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Request for Compensation CA7 Sections 8 9 Tab The Sections 8 9 tab contains the employee s pay rate information both current and pay when work stopped along with their work schedule This tab is available only to workers compensation personnel CAT Request for Compensation Form Select Claim Claim Person Date of Incident Type Sections 1 2 Sections 3 4 Sections 5 6 Sections 8 9 Sections 10 13 Sections 14 15 SECTION 8 Show Pay Rate as of Additional Pay 4 Date of Injury O Base Per Amount Grade mn Step Add EA Delete Per Date Employee Stopped Work Additional Pay Stopped Work Date O Base Pay Per fo Amount Grade Step
89. tions to navigate through the application OSHA For information on OSHA s recordkeeping requirements go to their website at http www osha gov where you can see the entire regulation on recordkeeping for injury and illness tracking in the work environment 4 ASISTS GUI V 2 0 User Manual June 2002 ASISTS Menus There are many different users of the ASISTS application the employee supervisor Occupational Health worker safety official workers compensation specialist and union representative Each user is assigned different privileges and a different set of menu options based on their role The ASISTS software is organized into the following menus Employee Supervisor Occupational Health Safety Workers Comp and Union File Employee Supervisor Occupational Health Safety Workers Comp Union Help ASISTS 2 0 Employee Menu All employees have VistA access and are assigned the Employee Menu options The Employee Menu provides the employee access to initiate a worker s compensation claim Other menu options ensure the employee has access to the Employee Bill of Rights as well as the ability to electronically validate and sign their claims Users of the Employee Menu can only see their own incidents The Employee Menu contains these options Complete Validate Sign CA1 Complete Validate Sign CA2 Employee Bill of Rights Request for Compensation CA7 June 2002 ASISTS GUI V 2 0 User Manual 5 ASISTS Menus
90. titlements include the option to receive medical treatment by either the VA Employee Health Unit or by your primary care physician you have the right to request union representation For additional information and explanation of your rights and responsibilities contact your Workers Compensation Specialist Coordinator Manager 0 Page 1 of1 68 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Enter Edit Location of Injury Detail This option can be found on the Safety Menu The Enter Edit Location of Injury Detail option is used to enter edit details on incident locations e Select a station and location of injury from the dropdown lists e If you are adding a new detail click the Add button Enter the text maximum 30 characters and click the OK button Click the Save button to save your entry e If editing an existing detail select the detail in the Location of Injury Details box and click the Edit button Edit the text as necessary and click the OK button Click the Save button to save your entry Location of Injury Detail entries may not be deleted This would invalidate any existing cases that were linked to the entry Enter Edit Location of Injury Detail DAYTON 552 FE 3 naineering sho Enter Location of Injury Detail Metal Shop Cancel June 2002 ASISTS GUI V 2 0 User Manual 69 Option Documentation Enter Edit Location of Injury Detail Enter E d
91. u o Bev EE 5 EMPLOYEE MENU ete emet tete e eee eec de ie ello eoe tee eee ete oet eee e eoi eae 5 SUPERVISOR ie cet ee ey ecd v heec eec e eee eec piv ec Eee ce re dU E eo bete ee e E d e t 6 OCCUPATIONAL HEALTH MENU re erem eoe etes ee tee ce ee eeu tree ses dt 6 SAFETY MENU cete eo he ee tec e P ec re do heec E E pA o e REED e T WORKERS COMP MENU 2 2 E E Eae e E e T E EEE EEE Ea ee eee 8 UNION ESE EEE EEEE EE AE ETE 9 COMMON SCREENS E E eiae EE EE eoe 10 ASISTS Select Case SCH CM os 5 E AAO EA EEE E EEEE 10 IAA ARTA EARNE AA EIENEN EAEE N TEE OE 11 Duplicate Record SCre n e aie eet p tbt e eder Pete e e te ee 12 OPTION DOCUMENTATION o M 13 CHANGE STATUS OF CASE ree eR ERE nn ER ERE ET ERE 15 CLASSIFY INCIDENT OU UTCOME eie EH eere RE EE S REESE BEER ERR REPE EP EB tre ITO 16 COMPEERTE VALIDATE SIGN CA beret e e ER E EE CURE EP PEE EAR oi RR REB EEG Reid 18 Injury Witness Data Tab e e NT Due aas 20 ARON CY t vb RI RA RR FERE AR RIED ARP IER RR RENE OE 21 WorkSchedule ene nieht RID Reb iet ete eed e 22 Third Part Tab a Rn Re pU d e nar tee E Ee EC ERR NR en 23 Physician Tab uiis ERE ERE RET TRIER EE AFER UTER Te eaves he dts 24 Filing Instr
92. uctions Tab use AER YER ERN 25 OWGP T ab i eese RR nC 26 COMPEETE V ALIDATE SIGN Q A2 eee ctc texte ere ede eee tet eee eet Eee gate ree e vette ree DE ds ce 29 Employee Data Tab oi Ie eb eSI eto sa ects ERE de REIR eod eee 30 Claim Information Tabien ed ob uet te Ue PRO ea ded een 31 Apency Tb cec Ape tds nit e sats pod teta t doe mn in ette e petet ce a ceste obe 32 Work Schedul Tabi sensuelle 33 Thira Party T bi ui aie nn ete 34 PHYSICIAN Tabs 4e e needs e e P t e tot lp site nr ren doa 35 Signatures Tab sei eter tat t e dto e i t dee ede e Ete creta nue obtenu ee 36 OWE BET GD Em 37 COMPLETE V ALIDATE SIGN INCIDENT REPORT ccccccscscscsccccececececeeececececececececececeeecacecececacesseasassseuesasseaseeeeeeenaes 40 Employee Data Tab unie te dere ae ee du dii e Batten te 41 General Setting Tab iere ir d p Ee RE HEU EN E eo ERES 42 Other 43 Exposure TAD siecle d EBORE 44 Equipment Tablier 45 OS TACT GD seek Re 46 AITATIHTITRAK I Ems 47 June 2002 ASISTS GUI V 2 0 User Manual iii Table of Contents CREATE AMENDMENT 5 nan Re p rese re e iren re ii in 48 CREATE INC
93. une 2002 ASISTS GUI V 2 0 User Manual 15 Option Documentation Classify Incident Outcome This option can be found on the Safety Menu under OSHA 300 Options This option will enable either the safety official or workers comp specialist to track how the incident impacted the individual This screen is used to enter incident outcome data for any work related case which is recorded on the OSHA 300 Log The system will calculate the total days the individual has accumulated for all added incident outcome classification entries The result will be the summation of the actual number of days for both Away From Work and Job Transfer Restriction entries If the calculated total days for a specific case exceeds 180 days the maximum number of days that will be reported for that case on the OSHA 300 Log will be 180 days Cases available for incident outcome classification include both Open Closed cases as well as any case that has been electronically transmitted to the National Database or the Department of Labor Deleted and Replaced by Amendment cases cannot be selected The four Incident Outcome Classifications are as follows e Other Recordable This classification can only be selected for the first entry for an individual This is a recordable event from the 29 CFR1904 Occupational Injury and Recording and Reporting Requirements e Job Transfer Restriction This classification is selected when an employee is restricted from perf
94. upervisor or secondary supervisor Required fields are indicated with a double asterisk 18 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA1 Employee Data Tab The Employee Data Tab is the main entry edit point for processing CA 1 claims Only the employee and or the workers compensation specialist may enter data on this screen If the employee is incapacitated the workers compensation specialist may electronically sign for the employee via the Electronically Sign for Employee option The supervisor can see the fields on this screen but may only edit the Supervisor or Secondary Supervisor fields To make changes to the data on this screen use the Edit Validate Stub Record menu option Worker s Compensation Edit Employee CA 1 Form Select Claim y SSN Injury lliness Personnel Status Service Type Incident Employee Data njury witness Data Agency Work Schedule Third Party Physician Filing Instructions OwCP Employee Data Request Information Name Date of This Notice 55 Request Pay or Leave X Date of Birth TR Place Where Injury Occurred Information C Fem C M 5 Location HomePhone Address Grade Step Home Address SS cyl SS City State Zip State Zip Code Supervisor Dependents M Secondary Supervisor Ju
95. x noit te dite moet eese eet e e B te ERI 109 Sections LOIS aD aac ten eie mtem teet etis 110 Sections I4 I9 Tabs au eet mote eei e e ee nan venient inner ane TIN 111 SUMMARY INCIDENT REPORTS ret e e ERREUR EE EXFL TREE ERE C ER ERE EE EPIO NER TCR NE PRU NER 112 ABOUT ASIS ES dT 115 TECHNICAE SUPPORT EEEE amendement ur AE 115 RELEASE NOTES ce de E ETE VENTE TENER VER ERE ER OR CER ERES 115 iv ASISTS GUI V 2 0 User Manual June 2002 Introduction Welcome Welcome to ASISTS GUI V 2 0 This Graphical User Interface GUI version of the Automated Safety Incident Surveillance Tracking System ASISTS software package combines exciting new features with the established functionality ASISTS users have come to rely on ASISTS GUI V 2 0 is a full featured automated accident and illness reporting system designed for the Department of Veterans Affairs Background The ASISTS software package stores data on accidents causing injuries and illnesses reported via the Report of Incident The employee may choose to apply for compensation using the Federal Employee s Notice of Traumatic Injury and Claim for Continuation of Pay Compensation CA 1 when the incident is an injury and the Notice of Occupational Disease and Claim for Compensation CA 2 for an illness Statistical reporting is performed on incidents occurring nationwide by extracting pertinent Report of Incident data f
96. y Name gt Was Employee Injured in Performance of Duty 1 Street Yes Z Nof City State Zip Date Employee first received medical care E Does your Knowledge of the Facts agree with Statements of the Employee L Yes 8 No 8 v Do medical reports show employee is Disabled for Work Yes 3 _ 1 Prev Next June 2002 ASISTS GUI V 2 0 User Manual 23 Option Documentation Complete Validate Sign CA1 Physician Tab Information pertaining to the physician providing medical care agency controvert of claim and agency dispute of claim is on this tab Worker s Compensation Edit Employee CA 1 Form Select Claim Y SSN Injury IlIness Personnel Status Service Type Incident Employee Data Injury Witness Data Agency Work Schedule Third Party Physician Filing Instructions OWCP Morse Par Does the agency controvert this al Does the agency dispute this claim Physician Name 6 Ye C No C Yes 3 Nola Reason For Dispute Code Title ind Street State the Reason in Detail City State X Zip m Reason for Controvert C a The disability was not caused by a traumatic injury b The employee is a volunteer working without pay or for nominal pay or a member of the office staff of a former President C The employee is not a citizen or a resident of the United State
97. y that the information given above and that furnished by the employee is true to the best of my knowledge with the following exception Exception 9 Supervisor Title Office Phone fis Extension Once you have electronically signed the 2 it is your responsibility to Print a hardcopy of the form Sign the hardcopy in blue ink Have the Employee sign the hardcopy in blue ink Deliver the hardcopy to HRMS immediately 36 ASISTS GUI V 2 0 User Manual June 2002 Option Documentation Complete Validate Sign CA2 OWCP Tab Information only available to OWCP personnel 15 located on this tab 2 Worker s Compensation Validate and Sign CA 2 form Select Claim FRERE RE SSN Injury lliness Personnel Status Service Type Incident Employee Data Claim Information Agency Work Schedule Third Party Physician Signatures OWCP OWCP Chargeback Code OWCP Chargeback Code Suffix OWCP District Office OWCP Nature of Injury Code Injury Type Code Injury Source Code Approve For Transmission to DOL June 2002 ASISTS GUI V 2 0 User Manual 37 Option Documentation Complete Validate Sign CA2 Prevention of Dual Benefits In order to prevent a veteran from receiving dual benefits for the same injury or death Federal Employees Compensation Act FECA Section 8116 a Dual Benefits form will be attached to the CA2 claim This form must be signed by both the employe

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