get started now to meet the application deadline · 2016. 2. 15. · *new* accg - gsiwcf safety...
TRANSCRIPT
For Members of the ACCG Insurance Programs
Get Started NOW to meet the Application Deadline
September 15, 2016
PLEASE READ This step-by-step workbook will assist you in qualifying for the safety discount.
The Safety Discount Program is an ongoing, year-round
process.
To be eligible for the ACCG Safety Discount during the 2017 policy year, please complete the requirements outlined in this booklet between
January 1, 2016 and December 31, 2016.
*NEW* ACCG - GSIWCF SAFETY ACTION PLAN *NEW* The SAFETY ACTION PLAN is a new requirement for the ACCG – GSIWCF members this year. The Member Organization's leadership and safety team is required to review their workers’ compensation loss trends over the last five years. The next step is to develop goals that will address risk causing the most claim activity.
ACCG and LGRMS will conduct several webinars in March 2016 to outline this requirement and answer questions. See page 12 for more information.
The SAFETY DISCOUNT VERIFICATION FORM can be sent anytime during the year.
Please copy the applicable SAFETY DISCOUNT VERIFICATION FORMS included in this booklet. The FORMS will NOT be sent in a separate mailing.
SUBMIT THE ACCG SAFETY DISCOUNT VERIFICATION FORMS
ANYTIME During the Year, BUT NO LATER THAN September 15, 2016
Please contact Penny Henderson if you have any questions. 404-589-7834 or [email protected]
191 Peachtree Street NE Suite 700 Atlanta, Georgia 30303 p 800.858.2224 fx 404.522.1897 accg.org
DATE: January 2016 TO: ACCG - IRMA Insurance Contacts & Safety Coordinators ACCG - GSIWCF Insurance Contacts & Safety Coordinators COPY: ACCG - IRMA & ACCG - GSIWCF County Chairmen & Managers ACCG - GSIWCF Executive Directors FROM: Penny J. Henderson ACCG Insurance Programs SUBJ: ACCG Safety Incentive Discount Program ACCG - Interlocal Risk Management Agency 2017 - 2018 Policy Period ACCG - Group Self-Insurance Workers' Compensation Fund 2017 Policy Period ACCG Insurance Programs encourages workplace safety as a win-win for the member and its employees. When safety is practiced in the day-to-day operations, everyone benefits by minimizing the number and severity of losses impacting the lives of your coworkers and citizens. Saving a life is the greatest advantage of the Safety Discount Program! ACCG Insurance Programs promotes a safer environment by offering a significant premium discount for those members who elect to participate in the Safety Discount Program. Not only can this program save the lives of citizens or employees, it can reduce the member's premium by controlling the losses and payouts to claims, thereby decreasing future insurance costs. The ACCG - Interlocal Risk Management Agency Board of Trustees has approved a 5% safety discount, to a maximum of $5,000 on the property and liability premium. Last year, 98 of our 109 eligible members met the qualifications to receive the discount, resulting in premium savings of over $465,000 during the 2015 - 2016 policy year. This program is designed for counties to avoid or minimize the severity of their property and liability losses with an emphasis on law enforcement; therefore, the discount is not applicable to authorities.
ACCG Safety Discount Program January 2016
The ACCG - Group Self-Insurance Workers’ Compensation Fund Board of Trustees has approved a 7.5% discount on the 2017 workers’ compensation premium. In 2016, 81% (135) of the 166 ACCG - GSIWCF members qualified for the discount, collectively saving over $2.7 million dollars on their 2016 premium. The discount is available for both counties and authorities. Members of ACCG – GSIWCF and ACCG – IRMA must meet all of the requirements to be considered for the safety discount. To qualify for the Safety Discount, a member must agree to implement and maintain a basic safety program and appoint a Safety Coordinator. For your organization to receive a Safety Discount, please review the specific standards outlined in the 2017 ACCG Safety Discount Program booklet. Detailed instructions on 'HOW TO COMPLY' are outlined on page 5 in the workbook.
THE SAFETY DISCOUNT PROGRAM IS AN ONGOING, YEAR-ROUND PROCESS.
o Part of the application process is for the members of each Insurance Program to complete the SAFETY DISCOUNT VERIFICATION FORM.
o A SAFETY DISCOUNT VERIFICATION FORM is to be signed by the County
Chairman or the Executive Director (if your organization is not a county).
o The form from each Insurance Program will only need to be submitted once. It is not necessary to send the original. If confirmation upon receipt is necessary, then please send via fax or email and retain your evidence of transmittal.
o SEND ANYTIME during the year, but no later than September 15, 2016.
o Once the requirements are met and the form(s) is submitted, the
application process is finished. After ACCG receives the forms from the members, a copy is forwarded to LGRMS.
o If the safety discount application is NOT submitted, then your organization
will NOT be eligible for the discount.
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ACCG Safety Discount Program January 2016
Our members have access to an exceptional resource of safety and loss control expertise through Local Government Risk Management Services. LGRMS is a non-profit organization sponsored by the Insurance Programs of the Association County Commissioners of Georgia and Georgia Municipal Association. All of LGRMS’ services are provided at no additional charge to ACCG - IRMA and ACCG - GSIWCF members. Each member of the ACCG Insurance Funds is assigned a LGRMS field representative to provide expertise in loss control and safety. Steve Shields, Chris Ryan, John McIntyre and Natalie Sellers are the LGRMS loss control representatives. They are available to share their knowledge with our members in implementing and maintaining a successful safety program. LGRMS will perform an annual audit to confirm the safety criteria and training requirements have been met. Please see page 21 since the Field Representatives' districts have been changed. If you have any questions about the ACCG Safety Discount Program, please call me at 404-589-7834 or 800-858-2224. You may direct your training inquiries to Shamilla Jordan at LGRMS 678-686-6282. LGRMS can also be reached at 678-686-6279 or 800-650-3120 for technical assistance or contact your LGRMS field representative noted on page 20. cc: David Uhlman, Property & Casualty Insurance Program Director Dan Beck, Director of Local Government Risk Management Services
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ACCG Safety Discount Program
ELIGIBILITY REQUIREMENTS
INTERLOCAL RISK MANAGEMENT AGENCY [Property & Liability]
and
GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND Members of the ACCG Insurance Programs who comply with the following safety incentive discount requirements will be eligible to receive a discount on their annual insurance premiums. ACCG – IRMA 5% discount July 1, 2017-18 Policy Year
[Counties only] [maximum of $5,000] ACCG – GSIWCF 7.5% discount January 1, 2017 Policy Year The required procedures are the foundation for an effective safety program, and are used as a basic guideline for implementing a loss control and safety program. ACCG Insurance Programs encourages its members to provide a safer workplace by adding additional procedures based on the needs of the organization.
The ACCG SAFETY DISCOUNT VERIFICATION FORM must be completed and submitted to ACCG Insurance Programs by September 15, 2016. Local Government Risk Management Services will be notified and will make an appointment to conduct the safety audit. Once the confirmation is received from LGRMS indicating the member has passed their audit, the discount will be applied to your annual insurance premium.
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HOW TO COMPLY with the following standards to receive the safety discount. THE REQUIREMENTS BELOW APPLY TO MEMBERS OF BOTH INSURANCE PROGRAMS.
1. A SAFETY COORDINATOR MUST BE APPOINTED. The Safety Coordinator may be any person who works in the organization. A new position does not need to be created in order to comply with these standards. One individual may serve as the ACCG - IRMA and ACCG – GSIWCF Safety Coordinator. The Safety Coordinator is responsible for working with management to coordinate the actions below.
SAFETY COORDINATOR RESOLUTION [Appendix A]
o ATTEND SAFETY COORDINATOR MODULES I, II, OR III training presented by
Local Government Risk Management Services (LGRMS). A Safety Coordinator is required to take one Safety Coordinator class per year until they have completed the all of the modules. Once all three sessions have been attended by the Safety Coordinator, the SAFETY COORDINATOR TRAINING MODULES will not need to be repeated, as long as the Safety Coordinator does not change. In the event a new Safety Coordinator is appointed by the member, the new Coordinator will need to complete the training.
o COORDINATE QUARTERLY SAFETY MEETINGS. A minimum of four safety review meetings must be held each year. If all four of the meetings have not taken place by the time the SAFETY DISCOUNT VERIFICATION FORM is due, they must be scheduled to take place in quarterly increments throughout the policy year. A record of the meeting, including topics discussed and a sign-in sheet to verify those in attendance should be maintained to document compliance with this requirement. LGRMS will provide assistance in implementing and holding safety meetings, if requested.
o COORDINATE SAFETY TRAINING AND IMPLEMENT SAFETY RULES for
supervisors and employees. They will ensure that appropriate documentation is posted at or near job-sites that instruct injured employees how they should proceed in the event of an on-the-job accident.
o COORDINATE SAFETY INSPECTIONS to help identify potential claim exposures.
Items to be documented for periodic inspections are all county vehicles, buildings & grounds, equipment & machinery, and work practices & procedures. LGRMS can provide county members with checklists and other assistance to help comply with this requirement.
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o REVIEW ALL INCIDENTS AND ACCIDENTS [INJURY OR PROPERTY DAMAGE]
involving employees and the general public to determine the cause, make recommendations for improvements to prevent or minimize future occurrences. Document and maintain records and implement follow-up actions.
The following is a suggested timetable for the Safety Coordinator: January, February and March.
o Schedule a safety meeting for the first quarter.
o Register an employee to attend a LGRMS workshop to satisfy the training requirement.
o Register to attend the LGRMS Safety Coordinator Modules I, II, and III, until all are completed.
o Conduct safety inspections.
April, May and June.
o Present another quarterly safety meeting.
o Ensure an employee will participate in a LGRMS workshop.
o Attend a LGRMS safety coordinator training course, if necessary.
o Comply with the other pertinent standards listed in the workbook.
July, August and September.
o The third quarterly safety meeting is to be held.
o Confirm an employee has attended the LGRMS workshop to satisfy both the IRMA and GSIWCF training requirement.
o Review all incidents and accidents.
o Coordinate safety inspections with LGRMS Field Representative.
October, November and December.
o Complete the final quarterly safety meeting.
o Attendance is mandatory at the LGRMS workshop (if haven’t done so already).
o Meet all of the remaining eligibility requirements.
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2. An EMPLOYEE from your organization must attend a minimum of
ONE TRAINING SESSION administered by Local Government Risk Management Services, in addition to the Safety Coordinator attending the Safety Coordinator Modules previously described. The training can be on any topic LGRMS presents other than Health & Wellness workshops.
ALL TRAINING IS TO BE COMPLETED IN THE 2016 CALENDAR YEAR. However, you are encouraged to take advantage of the LGRMS training
opportunities prior to the fourth quarter due to course availability. On-site courses DO count towards the training requirement. On-line courses and Health & Wellness Workshops do NOT apply toward the Safety Discount. A schedule of training programs administered by LGRMS may be viewed on their website www.lgrms.com or obtained by calling 800-650-3120.
The single factor that most often prevents our members from receiving the Safety Discount is NOT completing the training requirement.
3. Members agree to cooperate and support the efforts of the
LOCAL GOVERNMENT RISK MANAGEMENT SERVICES’ safety and loss control programs. Members will be required to respond to LGRMS’ recommendations in writing within ninety (90) days following a loss control visit. Although the member does not have to conform to the recommendations explicitly, they must take the initiative in developing a plan to maximize LGRMS’ expertise, or provide an explanation as to why this opportunity for improvement was not taken.
4. The member shall implement and oversee a DRUG-FREE WORKPLACE PROGRAM
to include, at a minimum, the following: o A DRUG-FREE WORKPLACE NOTICE on all employment applications and/or in the
personnel policy. o A written DRUG-FREE WORKPLACE POLICY regarding drug or alcohol use in the
workplace. MODEL SUBSTANCE ABUSE POLICY [Appendix B] Exhibit A Observation Checklist Exhibit B Pre-Employment Consent & Release Form Exhibit C Safety Sensitive Positions
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5. A SEAT BELT POLICY must be implemented and enforced by the member. The
purpose of this policy is to establish mandatory seat belt use as an organizational priority and designate responsibility for implementation and enforcement. It is essential that DRIVERS and PASSENGERS use their seat belts while traveling on official company business. The SEAT BELT POLICY applies to all employees and occupants of any vehicle driven by employees, including rentals and personal vehicles when used on official company business. The driver of the vehicle is responsible for enforcing seat belt use by all occupants. When possible, it is also employees’ duty to use their seat belts while operating equipment. The member shall emphasize to the new employee the county/authority recognizes that seat belts are extremely effective in preventing injuries and loss of life in a crash. This commitment will be demonstrated by requiring a SEAT BELT POLICY by the county, and taking reasonable steps to enforce compliance with the policy. Managers and supervisors have an obligation to strongly encourage seat belt usage by communicating the benefits to their employees, monitoring compliance, evaluating effectiveness and taking disciplinary action against violations. SEAT BELT POLICY [SAMPLE 1 & 2] [Appendix C]
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ACCG
INTERLOCAL RISK MANAGEMENT AGENCY [Property & Liability]
The following requirements apply only to COUNTY MEMBERS of the ACCG Interlocal Risk Management Program (ACCG – IRMA).
AUTHORITIES are ineligible for this safety discount.
1. POLICY MANUALS must be in place as follows:
o A PERSONNEL POLICY MANUAL must be in place for all COUNTY DEPARTMENTS. This can be one policy manual or multiple policy manuals covering all county departments. All personnel policies must have a documented annual review and update. These policies should be included:
• Hiring / Termination • Employee / Supervisor Training • Harassment • EEOC & Non-Discrimination • Email / Internet Policy • Drug Free Workplace • Motor Vehicle
o SHERIFF OFFICES must have a written POLICY MANUAL in place. The manual must
have a documented annual review and update. The manual should be based on “Georgia Sheriffs’ Association Georgia Standards”. These policies should be included:
If different from County -
• Hiring / Termination • Employee / Supervisor Training • Harassment • EEOC & Non-Discrimination
Plus - • Motor Vehicle Operations • Pursuit • Use of Force • Arrests • Internal Affairs
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o SHERIFF DEPARTMENTS WITH JAIL FACILITIES must have a written POLICY MANUAL
in place. The manual must have a documented annual review and update. The manual should be based on “Georgia Sheriffs’ Association Georgia Standards for Adult Pretrial Detention Facilities”.
2. COUNTY JAIL FACILITIES which are operated by the SHERIFF’S DEPARTMENT
should be staffed to permit jailers and dispatchers to perform separate job duties. A Georgia Sheriffs’ Association Staffing Analysis & Report is recommended to help determine proper staffing levels for the jail operations. These policies should be included:
• Inmate Medical • Jail Suicide Prevention • Civil Rights
3. MOTOR VEHICLE REPORTS (MVR) must be obtained on all new employees
before they are allowed to drive county vehicles. Automobiles are a major source of liability losses for county government. The purpose of this requirement is to assist in determining the risks of drivers that are behind the wheel of county vehicles.
ACCG anticipates that this will be the first step in effectively controlling losses by setting policies in place to restrict the driving of employees with poor driving records, although this not a requirement to receive the safety discount. ACCG will continue to allow the counties to make their own decisions as to who will drive county vehicles during the course of employment.
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ACCG
GROUP SELF-INSURANCE WORKERS' COMPENSATION FUND
The following requirements apply to ALL members of the ACCG Group Self-Insurance Workers' Compensation Fund (ACCG – GSIWCF).
1. The following PERSONNEL AND ADMINISTRATIVE PROCEDURES are to be
included during the EMPLOYEE ORIENTATION for each new employee: o The PANEL OF PHYSICIANS and the BILL OF RIGHTS FOR THE INJURED WORKER
must be explained to each new employee by the member. A signature is required from each new employee indicating this has been accomplished.
o A valid PANEL OF PHYSICIANS must be posted and maintained in prominent places at each work site as required by Georgia law.
PANEL OF PHYSICIANS [Appendix D]
o A valid A BILL OF RIGHTS FOR THE INJURED WORKER must be posted and
maintained in prominent places at each work site as required by Georgia law.
A BILL OF RIGHTS FOR THE INJURED WORKER [Appendix E]
o Explain the policies that are relevant to the employee’s position. (e.g. SEAT BELT POLICY, RETURN TO WORK POLICY, etc.)
2. The member must have a RETURN TO WORK POLICY in place to encourage
various departments to accommodate the use of transitional employment, if an injured employee is unable to perform normal job duties during their recovery period. The member must make a reasonable good-faith effort to return an injured worker to work at a modified job, if approved by the doctor. The ACCG Claim Administration Services will notify the member when an employee has been released to modified duty, but it will be the member’s responsibility to make a reasonable search to determine if a position is available. RETURN TO WORK PROGRAM [Appendix F]
RETURN TO WORK POLICY [Appendix G]
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3. SAFETY ACTION PLAN
THIS IS A NEW REQUIREMENT FOR THE ACCG – GSIWCF MEMBERS THIS YEAR. It is important for the leadership and safety team to understand what’s causing or contributing to their workers’ compensation losses. The analysis provides valuable information on where to focus loss control efforts in the future to prevent or mitigate losses. In March, ACCG will provide the member's loss history to each Safety Coordinator for the analysis. The safety coordinator, county leadership and/or safety team are to agree on risk reduction goals for the remainder of the year, and complete a Safety Action Plan. The Safety Action Plan template is provided in the booklet. The Loss Control Field Representative is available to assist as needed.
SAFETY ACTION PLAN [Appendix H]
PLEASE NOTE: MARCH 2016 After the analysis is received from ACCG in March and the safety coordinator, leadership and/or safety team have reviewed applicable loss trends over the last five years, the auditors will want to view the developed goals which address the risks causing the most claim activity.
A SAFETY ACTION PLAN is provided in the booklet.
ACCG and LGRMS will conduct several webinars in March 2016 to outline this requirement and any answer questions.
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163 Members / January 2016Property & Liability
INTERLOCAL RISK MANAGEMENT AGENCY
Appling County10/09/1987
Atkinson County10/01/2010
Atkinson County Solid WasteAuthority
07/01/2010
Bacon County01/01/2006
Baker County05/01/2000
Baldwin County03/01/2003
Banks County10/01/1987
Bartow County01/01/2003
Bartow-Cartersville JointDevelopment Authority
05/01/2005
Bartram Trail Regional LibrarySystem
02/01/2003
Bleckley County01/21/2003
Brantley CountyBryan County11/01/1988
Bulloch County04/15/2004
Butts County12/01/1998
Butts County Water & SewerAuthority
02/01/1998
Carroll County Water Authority01/01/2003
Charlton County06/01/1991
Chattooga County03/05/2003
Clay County10/01/1987
Clinch County10/01/1987
Clinch County DevelopmentAuthority
02/01/2011
Coastal Plain Regional Library08/01/2006
Coffee County01/01/2005
Colquitt County07/01/1991
Columbia County10/01/1994
Conyers-Rockdale Library System07/24/2003
Cook County06/07/1997
Crawford County12/12/2000
Crisp County09/01/2001
Cusseta-Chattahoochee UnifiedGovernment
03/05/1998
Dade County03/01/1995
Dawson County03/01/1998
DeKalb Private Hospital Authority07/12/2012
Decatur County01/24/2005
Development Authority of BartowCounty
10/01/2004
Development Authority of DeKalbCounty
03/14/2012
Development Authority ofJefferson County
10/01/2002
Development Authority of MonroeCounty
01/22/2001
Development Authority of RabunCounty
07/20/2012
Dodge County05/25/1999
Douglasville - Douglas CountyWater & Sewer Authority
09/01/2003
Early County10/01/2002
Early County Department of PublicSafety
10/01/2004
Eatonton-Putnam Water & SewerAuthority
12/01/2007
Echols County ConsolidatedGovernment
02/03/1995
Effingham County10/01/1987
Ellijay-Gilmer County Water &Sewer Authority
07/01/2010
Emanuel County10/01/2000
Emanuel County DevelopmentAuthority
10/01/2002
Evans County01/01/1999
Fannin County12/01/1995
Fannin County Water Authority01/01/2015
Flint River Regional Library01/14/2003
Floyd County04/01/2005
Forsyth County12/31/2001
Franklin County11/24/1993
Franklin County Industrial BuildingAuthority
08/22/2012
Gilmer County02/15/2005
Glascock County08/01/2015
Glynn County04/25/2009
Gordon County10/01/1991
Grady County12/31/1987
Greene County01/01/1996
Greene County RecreationComplex
10/01/2007
Hancock County04/01/2007
Haralson County03/05/2014
Harris County10/01/2002
Hart County01/01/2003
Hart County Water & SewerAuthority
04/01/2007
Heard County10/01/2002
Henry County02/19/1992
Henry County Library System06/01/2002
Houston County07/01/2000
Houston County DevelopmentAuthority
04/01/2011
Jackson County07/10/1988
Jasper County10/04/1988
Jasper County Water & SewerAuthority
03/15/2001
Jeff Davis County03/02/2005
Jefferson County07/01/1993
Jefferson County Library System01/01/2003
Jenkins County05/15/2015
Johnson County10/26/1992
Jones County04/19/2005
Lamar County02/20/1988
Laurens County12/31/2000
Lee County01/13/2003
Lee County Utilities Authority07/15/2003
Long County04/01/1994
Lower Chattahoochee RegionalTransit Authority
08/17/2012
Lowndes County07/01/1994
Lumpkin County09/19/1997
Lumpkin County Water &Sewerage Authority
01/01/2001
McDuffie County01/15/2001
McIntosh County05/30/2002
McIntosh County IndustrialDevelopment Authority
07/01/2002
Meriwether County04/01/2006
Meriwether County Water &Sewerage Authority
08/04/2010
Middle Flint Regional 911Authority
08/31/2004
Miller County03/26/1995
Mitchell County01/17/1992
Monroe County02/01/1999
Montgomery County09/08/2002
Morgan County04/03/1991
Oconee County10/01/1987
Oconee County IndustrialDevelopment Authority
07/15/1997
Oglethorpe County04/15/1988
Paulding County07/01/1994
Paulding County Airport Authority11/12/2008
Paulding County IndustrialBuilding Authority
04/01/2007
Pierce County05/04/2004
Pike County12/31/1997
Pike County Parks and12/01/2009
Recreation AuthorityPolk County03/01/1996
Polk County Water, Sewage &Solid Waste Authority
06/12/2012
Pulaski County01/15/2004
Putnam County10/18/2003
Rabun County04/06/1992
Randolph County01/24/2015
Rockdale County07/01/1991
Satilla Regional Water & SewerAuthority
01/01/2002
Schley County12/31/2002
Screven County10/01/1987
Seminole County06/15/2008
Sinclair Water Authority07/01/2003
South Georgia Regional LibrarySystem
04/01/1997
Southwest Georgia RegionalCommission
07/01/2004
Stephens County12/31/1999
Stephens County DevelopmentAuthority
10/06/2005
Stewart County07/17/1988
Stewart County Water & SewerAuthority
07/17/1988
Sumter County01/01/2004
Talbot County05/01/2011
Taliaferro County04/26/2003
Tattnall County11/01/2004
Taylor County12/31/2012
Telfair County10/05/1992
Terrell County07/01/1992
Thomas County05/14/1993
Thomas County Public Library05/23/2011
Tift County02/01/1991
Towns County07/01/1996
Treutlen County07/01/1991
Treutlen County DevelopmentAuthority
10/01/2009
Tri County Joint E-911 Authority01/01/2006
Turner County08/01/1992
Twiggs County11/06/1993
Unified Government ofGeorgetown-Quitman County
10/01/1987
Unified Government of WebsterCounty
04/01/1998
Union County02/11/2002
Upper Oconee Basin WaterAuthority
09/11/1997
Valdosta-Lowndes Co.Conference Center & TourismAuthority
02/23/2000
Valdosta-Lowndes County AirportAuthority
06/04/1995
Walton County07/01/2007
Ware County07/15/1994
Washington County01/12/1988
Washington County AirportAuthority
10/01/2002
Washington County DevelopmentAuthority
10/01/2004
Wayne County10/01/1987
White County07/01/1999
Whitfield County01/01/2003
Wilcox County01/19/2003
Wilkinson County08/03/1993
02/15/2015
GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND Workers’ Compensation
166 Members / January 2016
ACCG 07/01/1982 Appling County 02/24/1983 Atkinson County 07/22/1982 Atkinson County Solid Waste Authority 07/23/1997 Bacon County 09/21/1983 Baker County 05/22/1985 Banks County 09/12/1982 Barrow County 10/15/1992 Bartow County *05/29/1991 Bartram Trail Regional Library System 02/01/2003 Ben Hill County 08/01/1991 Berrien County 01/22/1986 Bleckley County 01/10/1986 Brantley County 03/01/1983 Bryan County 01/29/1983 Bulloch County 07/02/1982 Burke County 08/06/1986 Calhoun County 04/01/1990 Candler County 01/10/1986 Carroll County *05/13/1985
01/01/2002 Carroll County Water Authority
01/23/1989 Catoosa County
05/05/1986 Charlton County
01/01/1986 Chattooga County
02/22/1984 Clay County
12/19/1986 Clinch County
11/04/1988 Coffee County
01/01/2006 Colquitt County
01/01/1983 Columbia County *
06/10/2003 Conyers-Rockdale Library System
04/07/1983 Cook County
01/01/2012 Crawford County
07/05/1985 Crisp County
04/19/1990 Crisp County Power
Cusseta-Chattahoochee Unified Government
03/16/1984
07/05/1985 Dade County
12/30/1982 Dawson County
07/10/1983 Decatur County
05/31/1993 Desoto Trail Regional Library
01/01/2009 Dodge County
10/08/1982 Dooly County
11/13/2009 Early County
Early County Department of Public Safety
10/01/2002
12/01/2007 Eatonton-Putnam Water & Sewer Authority
02/18/1983 Echols County Consolidated Government
09/01/1982 Effingham County
07/01/1982 Emanuel County
04/15/1983 Evans County
04/03/1984 Fannin County
02/19/1993 Flint River Regional Library
04/12/1986 Franklin County
08/29/1982 Gilmer County
02/27/1986 Glascock County
07/01/2012 Glynn County *
06/25/1984 Gordon County
12/19/1986 Grady County
07/02/1982 Greene County
07/27/2004 Greene County Recreation Complex
09/01/2000 Hancock County
10/01/2009 Haralson County
01/01/1990 Harris County Hart County 10/08/1982 Hart County Water & Sewer Utility09/25/2007
01/01/2002 Heard County
03/17/1992 Henry County *
06/01/2002 Henry County Library System
05/11/1995 Housing Authority Of Fulton County
11/20/2009 Irwin County
10/31/1985 Jackson County
02/23/1983 Jasper County
07/14/1986 Jeff Davis County
10/01/2009 Jefferson County
03/01/2008 Jefferson County Library System
04/14/1986 Jenkins County
04/03/1983 Johnson County Jones County 02/26/1983 Lamar County 11/30/1983 Lamar County Solid Waste Authority 01/01/2010 Lanier County 11/30/1983
07/01/1982 Laurens County
05/27/1986 Lee County
09/02/1991 Liberty County
11/07/2015 Lincoln County
07/14/1986 Long County
07/22/1982 Lowndes County *
10/30/2009 Lumpkin County
07/29/1987 Macon County
10/11/1985 Madison County
01/11/1983 Marion County
12/01/1983 McDuffie County
01/01/1994 McIntosh County
08/31/2004 Middle Flint Regional 911 Authority
09/28/1992 Middle Georgia Regional Commission
06/24/1986 Miller County
02/19/1983 Mitchell County
10/08/1982 Monroe County
03/30/1984 Montgomery County
02/25/1983 Morgan County
08/01/2008 Newton County *
02/26/1983 Oconee County
03/22/1993 Oconee Regional Library
01/05/1988 Oglethorpe County
05/13/1985 Paulding County
10/08/1982 Peach County
02/07/1986 Pickens County
11/15/1983 Pierce County
12/31/1983 Pike County Pike County Parks and RecreationAuthority
02/23/2012
Pike County Water & Sewerage Authority
06/01/2008
Polk County 04/09/1985 Polk County Water, Sewage & SolidWaste Authority
08/01/1990
03/01/2002 Pulaski County
07/01/1982 Putnam County
03/12/1983 Rabun County
11/06/2009 Randolph County
07/28/1984 Rockdale County
02/24/1994 Roddenbery Memorial Library
Satilla Regional Water & SewerAuthority
01/01/2002
04/29/1985 Schley County
07/22/1982 Screven County
01/10/1992 Screven-Jenkins Regional Library
06/15/1995 Seminole County
Sinclair Water Authority 01/01/2009 Solid Waste Authority of Crisp County 07/03/2012 South Georgia Regional Library System
04/01/1997
Southwest Georgia Regional Commission
07/01/2004
Spalding County *06/01/2005 Stephens County 01/01/1997 Stewart County 07/20/1988 Sumter County 01/01/1991 Talbot County 12/04/1982 Taliaferro County 07/01/1982 Tattnall County 02/07/1986 Taylor County 04/29/1985 Telfair County 08/01/1984 Terrell County 09/01/1988 Thomas County 07/22/1982 Thomas County Public Library 07/14/1992 Tift County 08/17/1982 Toombs County 04/27/1989 Towns County 10/01/1996 Treutlen County 07/01/1982 Tri County Joint E-911 Authority 01/04/2006 Troup County 12/15/1982 Turner County 02/08/1983 Twiggs County 03/10/1992 Unified Government of Georgetown-Quitman County
06/14/1984
Unified Government of Webster County
04/29/1985
Union County 04/20/1991 Valdosta-Lowndes Co. Conference
Center & Tourism Authority
11/01/2011
Valdosta-Lowndes County Airport Authority
07/01/1995
Walker County 02/01/2002
Walton County *04/01/2001Ware County 06/02/1983Warren County 03/16/1993
Washington County *07/01/1993Wayne County 03/21/1985Wheeler County 10/18/1983
White County 04/29/1985White County Water Authority 11/05/2009Whitfield County *09/01/2002
Wilcox County 02/07/1986Wilkes County 01/01/2013Wilkinson County 08/17/1982
Worth County 04/29/1985
* Large Deductible Member
01/01/2012 Lumpkin County Water & Sewerage Authority
SAFETY DISCOUNT VERIFICATION FORM
INSTRUCTIONS
1. Complete the appropriate SAFETY DISCOUNT VERIFICATION FORM in the booklet.
• The SAFETY DISCOUNT VERIFICATION FORM is also posted on our website.
WWW.ACCG.ORG [MEMBERSHIP SERVICES / INSURANCE PROGRAMS / SAFETY DISCOUNT FORM]
2. Copy a SAFETY DISCOUNT VERIFICATION FORM for each appropriate Insurance Program in which your organization participates.
3. Present the FORM(S) for signature to the County Chairman or an Executive Director of an Authority.
4. Scan & Email, Fax or Mail the applicable SAFETY DISCOUNT VERIFICATION FORM
• Send only 1 copy for each membership in the appropriate Insurance Program • Originals are not necessary
5. Confirmation of Receipt:
Faxed document: Set-up a transmission confirmation receipt using own location's fax
machine.
To Email a scanned attachment: Use the Options tab located at the top of a new email. Request a ‘delivery receipt’ and/or a ‘read receipt’ for evidence of transmission.
U.S. Postal Service Mail delivery: Request a 'signature upon receipt' Form from the
mailman. 6. The application process is complete when the requirements are met and the
SAFETY DISCOUNT VERIFICATION FORM is submitted for each Insurance Program that the organization is a member.
You may submit the SAFETY DISCOUNT VERIFICATION FORM anytime, since the Safety Discount Program is continual throughout the calendar year.
However, the FINAL DEADLINE to submit the ACCG SAFETY DISCOUNT VERIFICATION FORM(S) IS
September 15, 2016.
- 15 -
SAFETY DISCOUNT VERIFICATION FORM
QUESTIONS o Do you know if your organization is a county or an authority?
• ACCG Insurance Programs insures 2 types of members: COUNTIES & AUTHORITIES • County – the largest territorial division for local government within a state
of the United States [Georgia has 159 Counties].
• Authority – A separate entity that provides specific services to their citizens. [Examples are Water & Sewer, Library, Development, Recreation & Housing] Usually ‘AUTHORITY’ is part of the organization’s legal name. County Governments are NOT Authorities. IF YOU DO NOT KNOW - LOOK ON THE MEMBERSHIP LIST (PAGES 13 & 14) CALL YOUR LGRMS FIELD REPRESENTATIVE EMAIL [email protected]
o Is your organization a member of one or both of the following Insurance Programs?
• ACCG – Interlocal Risk Management Agency (ACCG – IRMA)
[property & liability]
• ACCG – Group Self-Insurance Workers’ Compensation Fund (ACCG – GSIWCF) [workers’ compensation]
IF YOU DO NOT KNOW -
THE ACCG - IRMA & ACCG - GSIWCF MEMBERSHIP LISTS ARE ON PAGES 13 & 14.
o The SAFETY DISCOUNT VERIFICATION FORMS can be sent anytime during the year,
but No Later Than September 15, 2016. • Each applicable form for the appropriate Insurance Program will only need
to be submitted once for the calendar year.
• Copy the forms provided in this booklet or on the website. www.accg.org
• The Safety Discount Verification Form will not be sent in a separate mailing.
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INTERLOCAL RISK MANAGEMENT AGENCY
[Property & Liability]
SAFETY DISCOUNT VERIFICATION FORM The members of the Board of Commissioners of ______________ ____ County (Name of County) hereby verify that they fully comply with the requirements of the Safety Discount Program.
______________________________________ ____________________________________ County Chairman Signature Date
The appointed ACCG – IRMA Insurance Contact is __________________________________ (County Contact receives invoices & renewals for property & liability) County Title________________________ Email Address:_________________________
The appointed ACCG – IRMA Safety Coordinator is __________________________ (Safety Coordinator is responsible for the Safety Program) County Title_______________________ Email Address:_______________________ If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the county in order to maintain a current database. Yes No SAFETY COORDINATORS COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)
ATTEND ONE LGRMS TRAINING COURSE __________________________________________ (COURSE / DATE)
Complete this form if your county is a member of the ACCG - IRMA (property & liability) Insurance Program. Send ONLY 1 COPY (if applicable) of EACH SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016.
Send to: Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303
Fax 404-522-1897 / Email [email protected] or [email protected]
- 17 -
COUNTIES [159 COUNTY GOVERNMENTS]
GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND
SAFETY DISCOUNT VERIFICATION FORM
The members of the Board of Commissioners of ______________ ____ County (Name of County) hereby verify that they fully comply with the requirements of the Safety Discount Program.
______________________________________ ____________________________________
County Chairman Signature Date
The appointed ACCG – GSIWCF Insurance Contact is __________________________________ (County Contact receives invoices & renewals for workers' compensation)
County Title________________________ Email Address:________________________
The appointed ACCG – GSIWCF Safety Coordinator is __________________________
(Safety Coordinator is responsible for the Safety Program)
County Title_______________________ Email Address:_____________________
If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the county in order to maintain a current database. Yes No SAFETY COORDINATORS COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)
ATTEND ONE LGRMS TRAINING COURSE _____________________________________________ (COURSE / DATE)
Complete this form if your county is a member of the ACCG - GSIWCF (workers' comp) Insurance Program. Send ONLY 1 COPY (if applicable) of EACH SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016 .
Send to: Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303
Fax 404-522-1897 / Email [email protected] or [email protected]
- 18 -
COUNTIES [159 COUNTY GOVERNMENTS]
ACCG - GSIWCF
SAFETY DISCOUNT VERIFICATION FORM
The Director of the ________________________________ _______ Authority hereby (Name of Organization) verifies that the organization fully complies with the requirements of the Safety Discount Program. ______________________________________ ____________________________________ Executive Director Signature Date
The appointed ACCG – GSIWCF Insurance Contact is __________________________________ (Authority Contact receives invoices & renewals for workers' compensation) Position_____________________________ Email Address:__________________________
The appointed ACCG – GSIWCF Safety Coordinator is __________________________ (Safety Coordinator is responsible for the Safety Program) Position___________________________ Email Address:________________________ If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the Authority in order to maintain a current database. Yes No SAFETY COORDINATORS
COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)
ATTEND ONE LGRMS TRAINING COURSE _____________________________________________ (COURSE / DATE)
If Member is an authority, send 1 COPY ONLY of THIS SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016.
Send to:
Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303 Fax 404-522-1897 / Email [email protected] or [email protected]
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AUTHORITY [NOT A COUNTY GOVERNMENT]
DEFINITION OF AUTHORITY: Separate entities created as a means of providing specific services to their citizens.
EXAMPLES: Water & Sewer, Libraries, and Development Authorities
DIRECTORY
LOCAL GOVERNMENT RISK MANAGEMENT SERVICES 3500 Parkway Lane, Suite 110 • Norcross, Georgia 30092
678-686-6279 • 800-650-3120 Fax: 770-246-3149
Loss Control Operations BECK, DAN Director of Loss Control (Direct Line) 678-686-6280 Email: [email protected] WATTS, DENNIS Training & Communications Manager (Business Cell) 404-821-3974 Email: [email protected] MADDOX, TERESA Office Manager (Direct Line) 678-686-6283 Email: [email protected] JORDAN, SHAMILLA Administrative Coordinator (Direct Line) 678-686-6282 Email: [email protected] Health Promotion Services ROBINSON, SHEREA Health Promotion Services Manager (Business Cell) 404-821-4741 Email: [email protected] AMOS, CANDACE Health Promotion Services Representative (Business Cell) 404-416-3379 Email: [email protected] RICHEY, LEIGH Health Promotion Services Representative (Business Cell) 404-295-4979 Email: [email protected]
Field Representatives McINTYRE, JOHN Southeast Georgia Field Representative (Business Cell) 478-954-9035 Email: [email protected] RYAN, CHRIS Southwest Georgia Field Representative (Business Cell)229-942-2241 Email: [email protected] SHIELDS, STEVE North Georgia Field Representative (Business Cell) 404-416-3920 Email: [email protected] SELLERS, NATALIE Central Georgia Field Representative (Business Cell) 404-904-0074 Email: [email protected] Public Safety Risk Consultants EARL, MIKE Southeast Georgia – Public Safety Risk Consultant (Business Cell) 404-558-8525 Email: [email protected] HYER, JULIE Southwest Georgia – Public Safety Risk Consultant (Business Cell) 404-615-2420 Email: [email protected] TROTTER, DAVID North Georgia – Public Safety Risk Consultant (Business Cell) 706-491-4015 Email: [email protected]
- 20 -
www.lgrms.com3500 Parkway Lane • Suite 110 • Norcross, Georgia 30092Phone 678 686.6279 • Toll Free 800 650.3120 • Fax 770 246.3149
Local Government Risk Management Services
Oconee
MurrayWhitfield
Catoosa
Walker
Gordon
Floyd
Pickens
BartowHall
Polk
PauldingCobb
Haralson
Gwinnett
DeKalbWilkes Lincoln
Rock-dale
NewtonMorgan
Walton
Greene
PutnamHancockJasper
Warren
Mc-Du�e
Columbia
Richmond
Glas-cock
Taliaferro
Henry
Clayton
Fulton
Fayette
Coweta
Carroll
Douglas
Heard
Troup Lamar Monroe JonesBaldwin
Upson
Harris Talbot
Taylor
Crawford
Bibb
Muscogee Peach
Twiggs
Wilkinson
Washington
Je�ersonBurke
Johnson
Emanuel
Jenkins Screven
BullochE�ngham
Candler
EvansBryan
TreutlenLauren
Wheeler
Mont-gom-
ery
Toombs Tatnall
Appling
Wayne
Long
Liberty
Chatham
McIntoshBaconCo�ee
Je� Davis
Telfair
Dodge
Wilcox
Pulaski
BleckleyHouston
Dooly
Crisp
TurnerBen Hill
IrwinWorth
Tift
Macon
Schley
MarionChatta-hoochee
Stewart Sumter
Quit-man
Randolph
Terrell Lee
ClayCalhoun Dougherty
Early
Miller
Baker
Mitchell Colquitt
Berrien Atkinson
Seminole
DecaturGrady Thomas Brooks Lowndes
Lanier
Clinch
Pierce
Brantley
Glynn
CamdenCharlton
Echols
Cook
Spalding
MeriwetherPike
Dawson
Web-ster
Butts
Ware
Forsyth
Dade Fannin
Union
Lumpkin
White
TownsRabun
Banks
Stephens
Franklin Hart
Haber-sham
Madison ElbertJackson
BarrowClarke Oglethorpe
Chattooga
Gilmer
Cherokee
Southwestern RegionChris [email protected]
Northern RegionSteve [email protected]
Southeastern RegionJohn McIntyre
Central Region Natalie Sellers
Field Representative Regions
- 22 -
- 23 -
SAFETY COORDINATOR
RESOLUTION
WHEREAS, ____________________County has agreed to establish the position of Safety
Coordinator to establish and oversee a safety program to assist with the loss prevention efforts of
the county;
WHEREAS, the Safety Coordinator will be responsible for insuring compliance with certain
safety rules and regulations that protect the well-being of county employees and the general
public;
WHEREAS, the Safety Coordinator will be responsible for:
• Establishing and coordinating safety meetings and self inspections to
identify safety related hazards;
• Coordinating and implementing safety rules and training for
supervisors and employees and/or making recommendations to
management regarding such items;
• Reviewing and/or investigating all employee accidents for causes and
making recommendations for improvements and corrections;
• Conducting periodic safety self inspections of all vehicles, buildings,
grounds, equipment and machinery, and work practices and conditions
to determine potential injury exposures;
• Documenting and maintaining inspection records and implementing
any follow up actions; and
Appendix A
- 24 -
WHEREAS, the Safety Coordinator can ensure that qualifications have been met that will
enable the county to receive a substantial discount discounts on their insurance costs.
NOW THEREFORE BE IT RESOLVED that the position of Safety Coordinator is
established for ____________________County.
RESOLVED this ______ day of ________________________, 20____.
BOARD OF COMMISSIONERS OF
__________________ COUNTY, GEORGIA
__________________________, CHAIRMAN
ATTEST:
_________________________________
County Commissioner or Clerk
Adopted: _________________________
Appendix A
- 25 -
MODEL SUBSTANCE ABUSE POLICY
I. Policy Statement
It is the position of ________ that alcohol and controlled substance abuse is a significant health problem in the United States today. The costs involved with this problem include human costs, such as lost jobs, morale problems, injuries, illnesses, and deaths, as well as economic costs, such as property damage, absenteeism, tardiness, lost productivity, increased health insurance costs, and the costs involved in replacing and retraining new employees. Further, in professions that serve the public, alcohol and substance abuse represents a real danger to the health and safety not only of the employees themselves, but also of the constituents served by those employees.
It is the objective of __________ to provide safe and effective public service. To meet this objective, the problem of alcohol and controlled substance abuse must be identified, confirmed and defeated. In order to achieve this, ___________ has developed a comprehensive alcohol and controlled substance abuse policy.
II. Definitions
Within this Substance Abuse Policy, and on any accompanying forms, thefollowing terms shall have the meanings associated therewith:
1) Controlled Substance shall have the meaning and include the substancesdefined as “controlled substances” in the Georgia Controlled Substances Act,O.C.G.A. § 16-13-20 and 16-12-21(4) as said Act shall appear from time totime.
2) Safety Sensitive Position shall be those positions where inattention to duty orerrors in judgment by the employee or applicant while on duty will have thepotential for significant risk of physical harm to the employee, otheremployees or the general public. A list of such positions is attached asExhibit C.
3) Confirmed Positive Result. Whenever an initial test for drugs or alcohol isfound to be positive, the laboratory will carry out additional tests pursuant tolaboratory testing guidelines to confirm that the initial positive indication wascorrect. If the second procedure also indicates the presence of drugs oralcohol, the test result will be considered a confirmed positive result.
4) Medical Review Officer shall mean a properly licensed physician whoreviews and interprets the results of drug tests and evaluates those resultstogether with medical history and any other relevant biomedical informationto confirm positive results.
III. Drug and alcohol use prohibited.
Alcohol and controlled substance use by employees during assigned workinghours, in ___________ buildings or on ____________ grounds, or otherwise while on
Appendix B - 26 -
official business shall be prohibited. This shall include the use or possession of controlled substances, the abuse of prescription medications, the possession of prescription medications by anyone other than the person for whom the medication was prescribed (except as required by official duty), and the use or abuse of alcohol. This prohibition (and the procedures set forth below) is in addition to any other drug and alcohol policy, including any policies or programs required by federal or state law.
IV. Types of testing to be implemented
1) Pre-employment testing: Because substance abuse is not easilydetectible in an applicant without the provision of a drug and alcoholscreening, and because the safety and health of employees and thehealth and safety of citizens depend upon a workforce free from drugand alcohol abuse, all job applicants being considered for employmentin positions for which pre-employment drug and/or alcohol screening isallowed by law, shall be required to pass a drug and/or alcoholscreening test prior to being hired. All job applicants shall be informedin advance that such testing shall be required, and postings for all jobsshall include a notice of this testing requirement. Pre-employmenttesting shall take place only after an offer of employment has beenmade but before employment actually commences.
2) Random and periodic drug testing: Employees in all positionsdesignated as safety sensitive, involved in drug interdiction, or havingunsupervised access to prisoners or contraband shall be required tosubmit to a drug and alcohol screening test at random or on a periodicbasis from time to time as determined by the department head and thepersonnel director.
3) Drug and/or alcohol screening test based on reasonable suspicion:
a. Any employee shall be required to submit to drug and/or alcoholtesting when there is reasonable suspicion to believe that suchemployee is under the influence or effects of drugs and/or alcoholimmediately before, during or immediately after assigned workinghours or while otherwise on duty or in control of government property.
b. Reasonable suspicion means a reasonable belief based on specificobjective and articulable facts and reasonable inferences drawn fromthose facts in light of experience. Situations that may give rise to aconclusion that an employee is under the influence of drugs and/oralcohol include, but are not limited to, the following:
i. An employee is involved in a physical or verbal altercation on thejob.
ii. An employee has an excessive number of incidents or accidents onthe job.
Appendix B - 27-
iii. An employee exhibits unusual behavior such as slurred speech orunsteady walking or movement on the job.
iv. An employee has an odor of alcohol or marijuana on their personon the job.
v. An employee is in possession of alcohol, drugs, or drugparaphernalia on the job.
vi. An employee is observed using illegal drugs or alcohol or hasexhibited the symptoms and manifestations of being impaired dueto alcohol or drug use.
vii. An employee has caused or contributed to an accident while on thejob.
c. In the event a supervisor determines that reasonable suspicion existsthat an employee is under the influence of drugs and/or alcohol, thesupervisor shall immediately report the incident to his/her immediatesupervisor or department head and shall complete the form entitledObservation Checklist (Exhibit A).
d. The determination of whether reasonable suspicion exists shall bemade by the department head or, in his/her absence, by the highestranking supervisory staff on-duty at the time.
e. Following the determination that reasonable suspicion exists, the factsunderlying the determination of reasonable suspicion shall bedisclosed to the employee at the time the demand to submit to testingis made. The employee shall be transported to and from the testingsite by the employee’s supervisor or a designee. Following the testingprocedure, the person transporting the employee shall makeappropriate arrangements to transport the employee home.
f. Supervisors shall be required to document in writing, by the nextworking day, the specific facts, symptoms or observations that formedthe basis for their determination that reasonable suspicion existed towarrant the testing of an employee All documents created inconnection with the determination of reasonable suspicion shall beforwarded to _________________.
4) Testing after accidents or injury: An employee in a safety sensitiveposition, an employee involved in the interdiction of illegal drugs, or anemployee who, in his/her job duties, is given unsupervised custody ofprisoners or contraband shall be subject to a drug and alcohol testconducted when, while on duty or just prior to going on duty:
a. The employee is operating a vehicle and/or equipment causing damageor bodily injury; or
b. The employee is involved in a fatality; or
Appendix B - 28 -
c. The employee is cited with a traffic violation; or
d. The employee sustains a work-related injury requiring medicaltreatment beyond first aid.
V. Prescription drug use
1) Any Employees using prescription medication while on the job shalldo so in strict accordance with medical directions. It is the employee’sresponsibility to notify the prescribing physician of the duties requiredby the employee’s position and to ensure the physician approves theuse of the prescription medication while the employee is performinghis/her duties.
2) The abuse and/or inappropriate use of legally prescribed drugs,including the performance of duties when the employee knows orshould know that he or she is potentially impaired due to prescriptiondrug use, shall be prohibited and shall be deemed a violation of thispolicy. Job performance or attendance deficiencies resulting from useshall be cause for disciplinary action up to and including termination.If any employee’s behavior or job performance gives rise to areasonable suspicion that the employee is abusing or inappropriatelyusing prescription medication, the employee may be required to submitto drug testing and to take leave until such time as the employee iscleared to return to work by the employee’s physician, the MedicalReview Officer, and the personnel director.
3) Employees and job applicants shall at the time of testing provide[Laboratory] with a list of those prescriptions and over-the-countermedications the employee recently has used. The list of medicationsshall be kept confidential until there has been a test result. The list ofmedications shall be disclosed only to the Medical Review Officer whowill determine whether the positive result was due to the lawful use ofany of the listed medications.
VI. Consent
Before a drug and alcohol test is administered, employees and job applicants willbe asked to sign a Consent Form (Exhibit B) authorizing the test and permitting release of test results to the employer and the Medical Review Officer. The consent form shall provide a space for employees and job applicants to acknowledge that they have been notified of the requirements of this policy.
Appendix B - 29 -
VII. Refusal to consent
1) Job applicants: Any applicant for a position for which pre-employmentdrug and/or alcohol screening is permitted by law who refuses to consentto a drug and/or alcohol test shall be denied employment, and anyconditional offer of employment shall immediately be rescinded.
2) Employees: Any employee who refuses to sign the required consent formor to submit to a drug and/or alcohol test as required shall be deemed tohave violated this policy.
3) No show: Employees who fail to appear at the designated collection site tosubmit to a required drug and/or alcohol test when so directed shall bedeemed to have refused to submit to the test shall be deemed to haveviolated this policy. A “no show” shall include any attempt to adulterate atest sample or otherwise frustrate, impair, or otherwise impede the testingprocess.
VIII. Testing laboratory guidelines
1) All testing procedures shall be administered and accounted for by anapproved laboratory and/or medical facility operating in compliance withthe National Institute of Drug Abuse (NIDA) or College of AmericanPathologists (CAP) guidelines.
2) Urine samples shall be provided in a private restroom stall or similarenclosure so that employees and applicants may not be viewed whileproviding the sample, unless circumstances require monitored testing.Outer garments, bags, briefcases, purses, or other containers will not bepermitted into the test area. The water in the commode shall be coloredwith dye to protect against dilution of test samples.
If the drug and/or alcohol test is to be conducted using a specimen otherthan urine (e.g. hair, saliva, blood, etc.), the sample shall be collected in amanner consistent with the privacy of the employee and the need tominimize the possibility of adulteration and/or mislabeling of the sample.
3) Whenever an initial test for drugs and alcohol is found to be positive, thelaboratory will then carry out additional tests pursuant to laboratory testingguidelines to confirm that the initial positive indication was correct. If thesecond procedure also indicates the presence of drugs or alcohol, the testresult is considered a Confirmed Positive Result.
IX. Confidentiality of test results
To the extent allowed by law, all information from an employee’s or jobapplicant’s drug and alcohol screening shall be confidential and only available tothe Medical Review Officer, department head, ____________ and those with a
Appendix B - 30 -
need to know at the discretion of ___________. Disclosure of test results to any other person, agency, or organization shall be prohibited unless written authorization is obtained from the employee or job applicant. In any case, the results of an initial positive drug or alcohol test shall not be released until the results are confirmed.
X. Violations of this policy
Any violation of this policy shall be handled in a manner consistent with disciplinary procedures.
XI. Employee assistance program
Referrals to an employee assistance program or rehabilitation program shall bemade in accordance with established employee assistance policies, if any.
XII. Drug and alcohol convictions
Consistent with the Federal Drug-Free Workplace Act of 1988, employees shallreport to his or her department head within five (5) working days any arrest or conviction made under a criminal drug or alcohol law and any charge made under a drug or alcohol law for which conviction could cause the loss of driving privileges. The department head shall then investigate and make appropriate recommendations to the personnel director.
Appendix B - 31 -
EXHIBIT A ___________________________ OBSERVATION CHECKLIST
Physical Signs or Conditions
1. Walking
___ Stumbling ___ Swaying ___ Staggering ___ Holding On ___ Unable to Walk ___ Unsteady ___ Falling
2. Standing
___ Swaying ___ Sagging at knees
___ Rigid ___ Unable to stand ___ Feet wide apart ___ Staggering
3. Speech
___ Shouting ___ Silent ___ Whispering
___ Slow ___ Rambling
___ Mute ___ Slurred ___ Slobbering ___ Incoherent
4. Demeanor
___ Cooperative ___ Polite
___ Calm ___ Sleepy ___ Crying ___ Silent ___ Talkative ___ Excited ___ Sarcastic ___ Fighting
5. Actions
___ Resisting communications ___ Fighting ___ Withdrawn or improperly talkative ___ Spends excessive amount of time on telephone ___ Displays violent behavior ___ Avoids talking with supervisor regarding work issues ___ Has exaggerated sense of
self-importance
6. Eyes
___ Bloodshot ___ Watery ___ Dilated ___ Glassy ___ Droopy ___ Closed
7. Appearance/Clothing
___ Unruly ___ Messy ___ Dirty ___ Partially dressed ___ Body excrement stains ___ Stains on clothing ___ Having odor ___ Neat
___ Clean
8. Breath
___ Alcoholic odor ___ Faint alcoholic odor ___ No alcoholic odor
9. Accidents
___ Taking needless risks ___ Disregard for safety of others ___ Higher than average accidents
on the job
Appendix B - 32 -
EXHIBIT B PRE-EMPLOYMENT DRUG TESTING
CONSENT AND RELEASE FORM
______________________________
I hereby consent to submit to urinalysis and/or other tests as shall be determined by _____________________ in the selection process of applicants for employment, for the purpose of determining the drug content thereof.
I hereby acknowledge that I have been notified of the requirements the ____________________ Substance Abuse Policy.
I agree that ______________________________________________________________ may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the ______________ for analysis.
I further agree to and hereby authorize the release of the results of said tests to ____________________.
I understand that it is the current use of illegal drugs that prohibits me from being considered for employment with __________________.
I further agree to hold harmless ___________________ and its agents (including the above named physician or clinic) from any liability arising in whole or in part, out of collection of specimens, testing, and use of the information from said testings in connection with __________________ consideration of my application of employment.
I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
Applicant: Print Name: _________________________________________ SS# ______________________________
Applicant: Signature: ___________________________________________ Date: ____________________________
Witness Printed Name: ___________________________________________________________________
Witness Signature: ______________________________________________________________________
Guardian Signature (if applicant/employee under 18): __________________________________________
( ) DRUG TEST
( ) BLOOD ALCOHOL
( ) BREATH ALCOHOL
( ) PRE-EMPLOYMENT ( ) CAUSE/REASONABLE SUSPICION ( ) POST-ACCIDENT ( ) RANDOM ( ) FOLLOW-UP TREATMENT ( ) OTHER ________________________
Appendix B - 33 -
EXHIBIT C SAFETY SENSITIVE POSITIONS
______________________________
List Employee Positions which pose a risk of substantial bodily harm during performance of employees' duties or use of equipment provided: (See II Definition #2 on Page 33)
Appendix B - 34 -
SEATBELT POLICY – SAMPLE 1 1. ____________________ County has declared that any and all passengers, including the driver, riding
in a vehicle owned by ____________________ County are required to properly wear installed seat belts
when operating a ____________________ County vehicle.
Exceptions are as follows:
a. Tractors/equipment not equipped with “Roll-Over Protection System” (ROPS)
b. Specialized construction equipment.
c. Prisoners/suspects of law enforcement officers being transported for short distances in the back
seat of the vehicle when restraining devices or other documented circumstances prevent the
proper wearing of seat belts.
d. Other exceptions must be requested in writing giving a full justification. Requests will be
addressed to the [Risk Management/HR/other] Department for approval.
2. Failure to use a seat belt is a serious safety violation and is not to be taken lightly. It is a known fact
that seat belts can and do help reduce the severity of injuries when they are properly used. Proper use
constitutes proper adjustments as well as proper latching of the unit. Employees who receive an auto
allowance or for any other reason for operating their personal vehicle on ____________________ County
business are required to wear their seat belts in their personal vehicles as well as those in
____________________ County vehicles. To bring employees into compliance with this policy:
First Offense: Will result in a written warning;
Second Offense: Will result in a two-day suspension without pay.
Third Offense: Will result in the loss of driving privileges for those who drive
_______________________ County vehicles;
Offense for Those who receive auto allowance: Will be the forfeiture of that allowance.
Appendix C
- 35 -
SEATBELT POLICY – Sample 2 Required Seat Belt Use: ____________________ County values the lives and safety of its employees. It is estimated that
seat belts reduce the risk of death in a motor vehicle crash by 45%, therefore
____________________ County has adopted the following policy concerning employee seat belt usage.
All employees and their passengers are required to use a seat belt when traveling in any vehicle
while in the course of conducting ____________________ County business. The requirement applies to
business travel in a vehicle owned by ____________________ County, in a rental vehicle or in a vehicle
owned by an individual employee, regardless of whether the employee is compensated for the use of
his/her vehicle.
If an employee is provided a county-owned vehicle that is used in the course of his/her
employment and is also available for that employee’s personal use, that employee, together with all
passengers who occupy the vehicle at anytime and for any purpose, whether business-related or
personal, are required to use seat belts at all times the vehicle is in motion.
The use of seat belts is to be considered a condition of employment with this company. Failure to
abide by this stated policy will be considered a breach of that condition of employment and subject the
person in violation to disciplinary action, including suspension and possible termination.
Appendix C
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THE PANEL OF PHYSICIANS What is a posted Panel of Physicians? A posted Panel of Physicians is a list of doctors from whom your employees may seek treatment if injured on the job. Although a minimum of six doctors are to be listed, representing six different medical practices, additional physicians are recommended. All of these doctors are to be updated on the most recent version of the State Board’s Form WC-P1. This is displayed along with the Bill of Rights for the Injured Worker. The Georgia State Board of Workers’ Compensation requires all employers to post these legal-sized documents in a conspicuous area in any location where employees are working. A Spanish version will also need to be posted for Spanish-speaking employees. Who is to be included to ensure a valid Panel of Physicians? A valid Panel of Physicians will comprise of no more than two industrial clinics, and at least one of the doctors listed should represent a minority group. An ophthalmologist and an orthopedic surgeon are also to be included on the Panel. It is recommended that no less than two orthopedic practices be available to enhance the likelihood that the employees are able to obtain an appointment swiftly. Why is a valid Panel of Physicians so important? Besides being required by law, having a valid Panel of Physicians posted at all times is a vital component in controlling the cost of workers’ compensation claims. Employees are required to seek treatment by physicians listed on the Panel. If a valid Panel is not in place at the time of a work-related injury, the employee will no longer be required to seek treatment with those on the Panel. Furthermore, these providers will be familiar with the Employer’s Workers’ Compensation program and be able to treat and closely monitor the employees on a consistent basis. They will be able to offer light duty options when warranted, and will remain committed in returning the employee to work as quickly as possible.
Appendix D
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Frequently Asked Questions How does a valid Panel of Physicians benefit the employer? • A valid Panel of Physicians allows the employer to ensure that its employees are
receiving quality, objective medical care from a physician familiar with Workers’ Compensation, which in turn controls the cost of your Workers’ Compensation claims and helps to minimize your premiums.
Is the employer required to post a valid Panel of Physician? • Yes. It is required by the Georgia State Board of Workers’ Compensation. In the
event that your Panel does not meet the requirements, your employees will be allowed to see any physician they choose. An invalid Panel may jeopardize eligibility for the ACCG Safety Incentive Discount Program.
Is the employer responsible for informing the employees of the posted Panel of Physicians? • Yes. The employees need to know the location of the Panel of Physicians at the time
of hire. They are to be directed to the Panel of Physicians when they are injured and assisted in setting the appointments with the doctors of their choosing.
Must the Panel of Physicians be posted on pink paper? • No. It is recommended that it be posted on pink paper for easy identification, however, there will be no penalty if it is not. Can several doctors from the same practice be placed on the Panel of Physicians? • Yes. However, if several different doctors are listed from one practice, physicians from five other practices will still need to be placed on the Panel. As an alternative, individual practices could be listed instead, and all doctors in that practice would be qualified to treat your employees.
Appendix D
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Should the doctors be contacted that are placed on the Panel of Physicians? • Yes. The physicians will have to agree to be available for the employees under Workers’ Compensation and be familiar with the Light Duty Program. The providers are to be contacted once every six months by the Employer to determine that the doctors are still practicing and accepting the employees. The Panel of Physicians is no longer valid, if even one doctor listed is not available to the employees at any given time. How often does the Panel of Physicians need to be updated? • The form itself needs to be updated whenever the Georgia State Board of Workers’
Compensation revises its documents. The State Board requires that the most recent version of the Panel of Physicians and the Bill of Rights for the Injured Worker be used. The existing Panel will need to be updated any time a change in physician or the medical practice is made.
Do older versions of the Panel of Physicians need to be retained when revisions are made? • Yes. A master copy of each updated Panel of Physicians with the effective date is
to be filed. The particular Panel that was in place at the time of an employee’s injury may need to be referenced.
Does the most recent version of the Bill of Rights for the Injured Worker need to be posted alongside the Panel of Physicians? •Yes. Otherwise, the Panel of Physicians may be deemed invalid. Where may the forms for the Panel of Physicians and Bill of Rights be found? • The website is http://sbwc.georgia.gov and select “Forms.”
ACCG - Claims Administration Services may be contacted at 404-614-2553 or 877-421-6298
Appendix D
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____________________ COUNTY
RETURN TO WORK PROGRAM POLICY: It is the policy of ______________ County to provide and establish a Return to Work Policy for employees with work-related injuries and illnesses who are unable, temporarily and/or permanently, to return to their permanent job duties. Because ___________ County recognizes that their employees are a valued and limited resource, this program is designed to:
• Assist the recovery process by providing a focus and a goal for return of the injured employee.
• Benefit employees by allowing them to return to full wages as soon as possible.
• Benefit employer by reducing workers’ compensation costs.
PROCESS: __________________County will seek return to work opportunities as quickly as medically possible through the use of transitional employment for all employees who are temporarily disabled due to an on-the-job injury. Transitional employment opportunities will be considered in all departments, not just the department in which the injured employee was working. Transitional employment assignments are intended to assist workers who are returning to work after a temporary disability that resulted from a work-related injury. All transitional employment duties must be productive. Duties must never be demeaning or appear worthless in any way. _______________ County, through their reasonable accommodation program, will make efforts to retain employees who are permanently disabled.
SAFETY DISCOUNT:
In compliance with the ACCG – 2016 Safety Discount Program,
________________ County agrees to adopt this Return To Work Policy.
____________________________ _______________________
COUNTY OFFICIAL SIGNATURE DATE
Appendix F
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RETURN TO WORK POLICY
Work Related Injuries or Illness
The County is committed to returning injured employees to work, within safe and healthy medical practices, as soon as practical. As soon as possible after the injury, and when the employee is medically able to return to work, a written medical release from the designated medical service provider must be received by the county personnel department. If the medical release specifies that the employee may return to work, the employee will be returned to work immediately or as soon as practical. The medical release should be on a county-approved PHYSICIAN’S REPORT FORM. The County reserves the right to require any treating physician to review the employee’s job description, including a description of essential duties, and express an opinion as to whether the employee may safely perform the essential job duties, before putting the employee back to work with or without temporary modifications or more permanent accommodations.
Appendix G
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#1234
#1234
#
1234
#
1234
Dept Leader of #2
Dept Leader of #1
Top Elected Official / Administrator /
Manager
Please Print Name Signature
StatusOwner's Name
Department's Risk Reduction Goal
Action Item Owner's Name Target Date Status
#2 Focus DepartmentDepartment's Loss Types Focus
Action Plan
Action Item Target Date
Department's Loss Types Focus
Loss Type
Department
Department's Risk Reduction Goal
#1 Focus Department
% of Claims Dollars
Top Departments by % of Claims Dollars
Top Loss Types by % of Claims Dollars
SAFETY ACTION PLAN
Year:
% of Claims Dollars
Member:
Loss Trend Analysis
Ed. 021016Appendix H
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