Workers’ Compensation

1. Workers’ Compensation UCLA Healthcare June 6, 2003

2. What Is the Purpose of Workers’ Compensation? • To provide legally mandated benefits to workers who are injured at work or who develop a job-related illness as a result of their employment • Benefits may include payment for medical bills, mileage, lost wages and vocational rehabilitation

3. Who Administers and Pays for Workers’ Compensation? • UC is self-insured and has selected Octagon Risk Services, an independent contractor, to administer our workers’ compensation claims. • Octagon Risk Services may discuss the claim with the department and the employee, investigate the injury/illness, and determine what workers’ compensation benefits the employee will receive. • Funding for the Workers’ Comp program is provided by the UC locations as a group. Each UC location is charged a premium amount per $100 of payroll based on the location’s overall claim performance.

4. When an Employee Is Injured on the Job . . . Claim Form Referral Slip Booklet/Checklist Provide the employee with: 1. A completed EMPLOYEE’S CLAIM FORM FOR WORKERS’ COMPENSATION BENEFITS This form must be provided within 24 hours of receipt of notice that an injury or illness has occurred as mandated by California state law. (Exception: first aid incidents) 2. A completed EMPLOYEE’S REFERRAL SLIP FOR INDUSTRIAL INJURY AND REPORT OF ACCIDENT 3. UCLA WORKERS’ COMPENSATION BOOKLET WHEN AN INJURY OCCURS & Workers’ Compensation Instruction Sheet

5. Employee’s Claim For Workers’ Compensation Benefits Instructions on how to complete the Employee’s Claim Form for Workers’ Compensation Benefits 1a. If the employee notifies you in person, the supervisor or department personnel representative must fill out lines 1, 9, 10, 11, 12, 13, 16, 17, 18 Have employee sign on line 8. Continue to step 2 • The employee may fill out the “employee” section of the claim form in your presence and return the form to you • If the employee chooses to fill out the “employee” section on their own, instruct them to mail the completed form to Healthcare HR 1b. If you receive notice of the employee’s injury by phone: supervisor fills out lines 1, 9, 10, 11, 12, 16, 17, 18. On line 11, fill in the date supervisor received phone report of injury. On line 12, fill in the date form was mailed to the employee • Certified mail is advisable as proof of mailing • Continue to step 2

6. Employee’s Claim For Workers’ Compensation Benefits (Cont’d) • Make a copy of the Claim Form and proof of mailing form for the department’s records. Department keeps the 5th copy “Employers’ Temporary Receipt” for department records. • Immediately FAX a copy of the completed form to the WC FAX line x 40530. 4 Employee keeps the 4th copy “Employee’s Temporary Receipt.” • Send all other copies of the form immediately to Healthcare HR for further distribution. 6. Notify Healthcare HR Workers’ Comp x40522 or via email to Cynthia Vazquez as soon as you are aware that an employee has been taken off work.

7. Employee’s Referral Slip For Industrial Injury And Report Of Accident Instructions on how to complete the Employee’s Referral Slip for Industrial Injury and Report of Accident. • Supervisor is responsible to complete this form describing how the injury occurred and where. Note the date the injury was reported. • Send the employee to the Occupational Health Facility with the Referral Slip. If OHF is closed, direct the employee to the Emergency Medicine Center for treatment. • Keep a copy of the Referral Slip for the department’s records. • Immediately FAX a copy of the completed form to the WC FAX line x 40535. • Notify Healthcare HR Workers’ Comp x 40522 or via email to Cynthia Vazquez as soon as you are aware that an employee has been taken off work.

8. Employee’s Referral Slip For Industrial Injury And Report Of Accident SPECIAL CIRCUMSTANCE #1: PRE-DESIGNATED DOCTOR If the employee reports he/she has pre-designated MD – • Advise the employee to obtain medical care with the pre-designated MD as soon as possible. He/She may go to Occupational Health or the Emergency Medicine Center for immediate treatment, if the employee desires. Pre-designation of a private MD does not bar the employee from getting treatment at OHF or the EMC. • Give and complete the WC Claim Form, Referral Slip. Provide When an Injury Occurs brochure and WC Checklist per previous instruction. SPECIAL CIRCUMSTANCE #2: : EMPLOYEE HAS BEEN RECEIVING OUTSIDE TREATMENT If the employee reports that he/she is being treated by a private MD – • Give and complete the WC Claim Form, Referral Slip. Provide When an Injury Occurs brochure and WC Checklist per previous instruction. • Send the employee to Occupational Health with any medical records/MD notes they have been given. • Advise the employee to contact Octagon Risk Services and give ORS the physician’s information.

9. Workers’ Compensation Process • Octagon Risk Services reviews the claim and determines what benefits the employee should receive. ORS notifies the employee by mail and by phone whether claim is accepted, delayed, or denied. • If the injury is delayed or denied, employee should file for disability benefits. Contact the employee’s supervisor or dept personnel rep to begin leave notification process. HR WC will direct inquiries to the department per the Benefits leave process. • If the injury is approved as work related and the employee receives a temporary disability check from ORS, HR WC will immediately notify the department. HR WC mails out Options letter to the employee. Department receives a copy.

10. Workers’ Compensation Process (Cont’d) • Workers’ Compensation payments for Temporary Disability or Vocational Rehabilitation will effect the employee’s pay. • The employee must use his/her sick leave for first three calendar days of the leave. • Follow the PTR instructions outlined in the next pages to pay the employee appropriately. • The employee needs to immediately choose how he/she would like us to treat his/her pay and notify Cynthia Vazquez in Human Resources, and the department: • Option 1 -- Employee elects to receive only the workers’ comp payments. • Option 2-- Employee elects to use sick leave only to supplement the workers’ comp payment. • Option 3-- Employee elects to use sick leave and vacation time to supplement the workers’ comp payment.

11. OPTION 1 Employee elects to receive only the workers’ comp temporary disability payments. • Revise the LOA Notification as ApprovedWC Option 1 and email to Human Resources Benefits Team and update the leave in EDB. • Immediately place the employee, if eligible, on FMLA leave without pay. • If not eligible for FMLA, place the employee on Workers’ Comp Leave Without Pay. • Use 09 for Workers’ Comp Code & clarify action on comments. • Do not report any time on WPS or EPRs. • Employee should receive no pay from payroll while receiving temporary disability.

12. OPTION 1 (Cont’d) • Employee is fully responsible for Benefits contribution according to the FMLA guidelines. • Employee must make employee contribution for health. • HR Benefits will notify the employee directly regarding all benefits which are not paid for by FMLA. • Employee will also need to pay directly for health, dental, and vision once the 12 weeks of FMLA exhaust. • Review the IDER and timesheet to determine if there was any payment of sick leave/vacation time. • Sick leave and vacation paid are considered “overpayment”. • Enter a reduction transaction “RX” for the overpayment amount. • When the employee repays the amount, the sick leave and vacation hours will be returned to balance by Hospital Payroll.

13. OPTION 2 Employee elects to use sick leave only to supplement the temporary disability payment. • Employee uses only a few hours SICK LEAVE each pay period to supplement temporary disability to equal 100% of his/her regular salary. • You will need to know: 1. The employee’s SICK LEAVE balance as of the date of injury/date when employee first began losing time. Refer to Accrual slips/Hospital Payroll/Timesheet. 2. The regular hours the employee would have worked for the dates listed on the WC worksheet. Dates are inclusive. 3. Any pay that the employee may have already received for the dates listed on the WC worksheet. Refer to the IDER screen. 100% salary TD + SL =

14. OPTION 2 (Cont’d) • Complete the Option 2 worksheet sent by HR WC. • IF the Balance is enough to cover the “Difference” then the employee remains at 100% pay for the WC Worksheet period. • Forward a completed copy of the worksheet via email to the Hospital Payroll representative for your department. • Hospital Payroll will update the sick leave balance and award full accruals to the employee. Sick leave may be used as accrued while @ 100% salary. • Enter the transactions on PTR per the PTR Manual and Payroll instruction. • Per University Policy, employee should receive shift differentials in addition to base pay. • Use DOS code REG for base pay. Use appropriate DOS code (e.g. NSD, SDF, etc.) in addition to base pay. Use DOS code WCR for WC check deduction. • PROCESS BY PAY COMPUTE DEADLINES! 14

15. OPTION 2 (Cont’d) • Revise the LOA Notification as ApprovedWC Option 2 and email to Human Resources Benefits Team and update the leave in EDB. • Place employee, if eligible, on FMLA Leave With Pay. • If not eligible for FMLA, place the employee on Workers’ Comp Leave With Pay. • Use 09 for Workers’ Comp Code & clarify action on comments • Once the employee’s own sick leave exhausts, the employee is eligible to receive 80% Extended Sick Leave benefit. • Reduce employee time on EDB to 80%. • Do not report any time on WPS or EPR’s • Department will process the pay on PTR

16. OPTION 3 Employee elects to use sick leave and vacation to supplement the temporary disability payment. • Employee uses only a few hours SICK LEAVE and VACATION each pay period to supplement temporary disability to equal 100% of his/her regular salary. Exhaust sick leave first, then vacation. • You will need to know: 1. The employee’s SICK LEAVE and VACATION balance as of the date of injury/date when employee first began losing time. Refer to Accrual slips/Hospital Payroll/Timesheet. 2. The regular hours the employee would have worked for the dates listed on the WC worksheet. Dates are inclusive. 3. Any pay that the employee may have already received for the dates listed on the WC worksheet. Refer to the IDER screen. TD + SL/VAC = 100% salary

17. OPTION 3 (Cont’d) • Complete the Option 3 worksheet sent by HR WC. • IF the Balance is enough to cover the “Difference” then the employee remains at 100% pay for the WC Worksheet period. • Forward a completed copy of the worksheet via email to Hospital Payroll. • Hospital Payroll will update the sick leave/ vacation balance and award full accruals to the employee. Sick leave and vacation may be used as accrued while @ 100% salary. • Enter the transactions on PTR per the PTR Manual and Payroll instruction. • Per University Policy, employee should receive shift differentials in addition to base pay. • Use DOS code REG for base pay. Use appropriate DOS code (e.g. NSD, SDF, etc.) in addition to base pay. Use DOS code WCR for WC check deduction. • PROCESS BY PAY COMPUTE DEADLINES! 17

18. OPTION 3 (Cont’d) • Revise the LOA Notification as ApprovedWC Option 3 and email to Human Resources Benefits Team and update the leave in EDB. • Place employee, if eligible, on FMLA Leave With Pay. • If not eligible for FMLA, place the employee on Workers’ Comp Leave With Pay. • Use 09 for Workers’ Comp Code & clarify action on comments • Once the employee’s own sick leave and vacation exhausts, the employee is eligible to receive 80% Extended Sick Leave benefit. • Reduce employee time on EDB to 80%. • Do not report any time on WPS or EPRs • Department will process the pay on PTR

19. 80% Extended Sick Leave Employee elected Option 2 or 3 and accrual bank has exhausted. • When an employee elects Options 2 or 3, the employee is eligible for this benefit once the SL or SL/VA in the employee’s bank is exhausted. • Department pays the employee the difference between [80% of regular salary based on appt] and the [WC temporary disability payment.] • 80% ESL does not come out of employee’s individual bank. • Benefit is paid for 26 weeks from the date employee exhausted his/her own SL or SL/VAC time on the WC worksheet and continues to receive WC temporary disability. • Employee continues to accrue SL/VAC @ 100 % but cannot use accruals until return to work or separation. TD + ESL = 80% salary

20. 80% Extended Sick Leave (Cont’d) • Calculate 80% of the employee’s regular hours based on appt for the dates listed on the 80% ESL Worksheet sent by HR WC. Dates are inclusive. • Forward a completed copy of the worksheet via email to Hospital Payroll. • Hospital Payroll will update the sick leave/ vacation balance and award full accruals to the employee upon return to work or separation. • Enter the transactions on PTR per the PTR Manual and Payroll instruction. • Per University Policy, employee should receive shift differentials in addition to base pay. • Use DOS code ESL for base pay. Use appropriate DOS code (e.g. NSD, SDF, etc.) in addition to base pay. Use DOS code WCR for WC check deduction. • PROCESS BY PAY COMPUTE DEADLINES!

21. 80% Extended Sick Leave (Cont’d) • Confirm the LOA Notification to Human Resources Benefits Team and confirm the leave is current. • Place employee, if eligible, on FMLA Leave With Pay. • If not eligible for FMLA, place the employee on Workers’ Comp Leave With Pay. • Use 09 for Workers’ Comp Code & clarify action on comments • Reduce employee time on EDB to 80%. • Begin and end date of 80% reduction in time can be found on 80% ESL worksheet. • Do not report any time on WPS or EPRs • Department will process the pay on PTR

22. AFTER 80% ESL • HR WC will notify the department rep to update the LOA Notification for the Human Resources Benefits Team and update the leave in EDB. • Email the LOA Notification promptly so HR Benefits can mail a disability packet to the employee. • Place the employee on Workers’ Comp Leave Without Pay. • Use 09 for Workers’ Comp Code & clarify action on comments • Correct employee time on EDB from 80% to original appt. • Do not report any time on WPS or EPR’s NOTIFY the HR Benefits Team via email on the Return to Work Notice form if the employee returns to work or pay status

23. AFTER 80% ESL (Cont’d) • Health Insurance coverage may continue -- • UC Regents will continue to pay the employee’s full health benefits (Employee and University contribution) via the Health Contingency Fund while the employee continues to receive temporary disability payments AND has not been separated from UCLA Medical Center. • Employee must make payment for all other insurances and Benefits that he/she wishes to keep current • HR Benefits will coordinate direct payment of premiums for all other benefits with employee.

24. General guidelines . . . • TIMESHEETS (EPRs/WPS) WAITING PERIOD -- • Fill out the WPS/EPR with first 3 calendar days of sick leave. • If the employee does not have enough sick leave to cover the first 3 days, the employee is entitled to receive 80% of his/her regular salary. Notify Human Resources, Cynthia Vazquez, if the employee does not have enough sick leave. • Record no sick leave/vacation on timesheet after waiting period. TO AVOID OVERPAYMENTS ONLY RECORD WAITING PERIOD AS SL: • Individual situations may be considered. Advise employees about potential overpayments if the employee requests sick leave/vacation pay while waiting for the WC paycheck. • UPDATE the LOA NOTIFICATION form as needed. • UPDATE the leave in EDB.

25. What else should you do? FMLA TIMELINESS HOLIDAYS PTO • FMLA • Provide the employee with a FMLA packet. • All workers’ compensation leaves are FMLA leaves if leave is more than 3 days. • TIMELINESS • Complete the worksheets and process in EDB and PTR as they are provided to you. If they are not processed, the employee does not receive pay, and benefits may be discontinued. • HOLIDAYS • Employees should receive FULL holiday pay while at 100% or 80% pay. Do not include holidays when calculating the hours worked for the worksheets. • PTO • If the employee on workers’ comp is eligible for PTO, immediately notify Enterprise Payroll. Send notification by e-mail to the department’s payroll representative and copy Lillian Wilson, Hospital Payroll. • While on Workers’ Comp, the PTO rules no longer apply and the employee’s accrual bank reverts back to vacation and sick time. 25

26. New Employee Pamphlet/Pre-designation of Physician NEW EMPLOYEE PAMPHLET • For employees hired on or after 01/01/03 New employees must be given written notice of workers’ compensation rights Includes a tear-off form to pre-designate their personal physician to treat them in the event of a work-related injury. Written notice must be provided to an employee no later than the end of his first pay period. Pamphlet with approved language available in Healthcare HR. PRE-DESIGNATION OF PHYSICIAN • Current form is available on the HR website • Current employees may utilize that form – only new employees must receive the whole pamphlet including the tear off form. • Employee must designate PRIOR TO AN INJURY the name and address of the MD or DO in writing. The doctor must be someone who had treated the employee before and who has the employee’s medical records.

27. PRE-DESIGNATION OF PHYSICIAN IF employee chooses to complete the form, HE/SHE must return the form to Human Resources as soon as he/she fills it out. HR will clock in date of receipt. HR must add the information to our database. HR will return the original form to the department to be retained in the employee’s personnel file. If department receives form from the employee, Clock in date of receipt. Forward copy of the form to HR immediately. Retain the original form in the employee’s personnel file. HR must add the information to our database.

28. Types of Injuries WC Basics Types of Injuries Indemnity • Examples: Repetitive motion, fracture, or sprain • Claims with lost time more than 3 days or anticipated permanent disability • Temporary disability, permanent disability, vocational rehabilitation, partial replacement of lost wages Medical • Claims with lost time of 3 days or less • May receive medical care and follow-up by Occupational Health or Workers’ Compensation medical provider First Aid • No medical treatment needed

29. Types of compensation WC Basics • Medical coverage • Medical examinations, therapy, co-pays, prescriptions, mileage, equipment, vocational rehabilitation • Temporary disability • Represents 2/3 of the employee’s regular salary, up to the current maximum of $602.00 per week for injuries occurring on or after 01/01/03. • Starts with the fourth calendar day the employee is unable to work. The three-day waiting period is waived if the employee is hospitalized or disabled for 14 days or more • Can also be WAGE LOSS which represents 2/3 of the employee’s lost earnings from the total average weekly earnings, up to maximum, when return to work on a part-time/modified basis • Vocational Rehabilitation • Training when employee’s injury prevents return to usual and customary job • Permanent disability • Long-term effects on ability to work are calculated, or “rated”, taking into account the body part affected, the occupation, the age and rate of pay at the time of the injury/illness.

30. OCTAGON RISK SERVICES 10880 Wilshire Blvd, Suite 850 Los Angeles, CA 90024-6914 Mail code 691448 Phone 310 794 8247 Fax 310 794 8268 OCCUPATIONAL HEALTH FACILITY(OHF) 200 UCLA Medical Plaza, Suite 224 Monday through Friday 7:30 a.m. to 4:30 p.m. Mail Code 172524 Phone 310 825 6771 Fax 310 206 4585 CAMPUS PAYROLL UCLA Wilshire Center, Suite 620 MC 141648 Phone 310 794 8706 Fax 310 794 8751 UCLA HEALTHCARE HUMAN RESOURCES 10920 Wilshire Blvd, Suite 400 MC 167648 Phone 310 794 0500 Fax 310 794 0530 EMERGENCY MEDICINE CENTER (EMC) BE-144 CHS Center for Health Sciences Open 24 hours a day Phone 310 825 2111 Fax 310 794 0599 ENTERPRISE PAYROLL UCLA Wilshire Center, Suite 1700 MC 167646 Phone 310 794 0127 Fax 310 794 8049 Assistance Directory

31. INJURY REPORTING PROGRAM INFORMATION INJURY ANALYSIS/TRENDS SUPPLEMENTAL PAYROLL WORKSHEETS Cynthia Vazquez Med Center Human Resources x 40522 DISABILITY MANAGEMENT RETURN TO WORK VOCATIONAL REHABILITATION LOSS CONTROL ASSISTANCE Mark Briskie Med Center Human Resources x 40525 CLAIM STATUS INJURY INVESTIGATION ASSISTANCE Claims Account Executive Octagon Risk Services (ORS) x 48247 phone ACCIDENT PREVENTION SAFETY INSPECTIONS/TRAINING ACCIDENT INVESTIGATION COORDINATION ERGONOMIC EVALUATION Victor Kennedy x 54012 200 Medical Plaza, Suite 202 692624 Daniel Phillips x 53389 Derick Nguyen x 45170 Building and Safety MC 694116 INFORMATION

32. Review a Workers’ Compensation Worksheet • Calculate Sick Leave and Pay Adjustments • Process a Leave of Absence in EDB • Process Pay Adjustments and a Workers’ Compensation Check in PTR

33. SAMPLE # 1 (OPTION 2) IMA EXAMPLE - OPTION 2 Title: Hospital __ Asst. I - 9252 Appointment: 100% (40 hr/wk, evening shift) Salary: $13.50 hr/ + $.85 SDF Injured: March 18, 2002 Sick Leave: 25.5 on date of injury Note: Accrual date on March 30, 2002 ORS Check: $720.00 (March 19-Apr 1, 2002) Returned to Work: April 2, 2002

34. ADD in full accruals of SICK LEAVE while on Option 2 This balance is left in employee’s bank.

35. WORKSHEET SAMPLE 1

36. IDERSCREEN Review IDER screen to verify if any hours have been paid during the pay period for which the adjustments are being made.

37. 9252 HOSP__ASST II EXAMPLE, IMA 987654321 031702- 033002- 0.00 0.00 32.00 8.00 03/29/02 03/17/02 03/18/02 03/19/02 03/20/02 03/21/02 03/22/02

38. EXAMPLE, IMA 03/17/02 03/30/02

39. Logging on to OASIS for PTR • Log on to Oasis • Oasis Menu Screen will appear, enter PPP • Online Application Main Menu • Go to Next Function field, enter EDAT, enter Employee ID#, then the Enter key/ Dept Adjustment Transaction menu will appear • Go to Next Function field: • Enter EDLR • Enter Employee ID# • Refer to “Schedule for Updating PPS ON-Line” and enter the Pay Cycle, I.e., B1 or B2 as appropriate • Enter the Pay Period End Date for the pay day on which the transaction(s) will be processed and then the Enter key The (EDLR) Dept. Adj. Trans screen will appear • Process LX and RX transactions from the Worker’s Comp Instruction Sheet • LX: REG 80.00 hours or ESL , and all other data, I.e., Title Code, Full Account Number, Rate, enter “H” in AH field • RX: WCR (worker’s comp payment) enter “A” in AH field • Go to F10 and enter comments, Go to F6 to add Payroll Notification and appropriate HR Benefits Team members as carbon copy recipients of the ASAP notification, Go to F3 to return to list of ASAP recipients, then F9 to Update transaction • Refer to PTR User Guide, Section E13, Special Processes for additional help

40. EDB - Leave of Absence OPTION 2 Leaves of absence due to a work incurred injury run concurrent with Family & Medical Leave. The leave should first be processed as a Family & Medical Leave, either with or without pay as appropriate. The comments on the ASAP notification should state that the employee is on worker’s comp and the time period. Once the employee has exhausted the Family & Medical Leave period and is still on worker’s comp, the leave type would then be 09 - Worker’s Comp.

41. PTR – Pay Adjustments OPTION 2 Worker’s comp check amount & end date of period covered Injured: 3/18/02 ORS Check: 0319 -040102 NEED TO ENTER THE LX FOR PPE 04/1302 8 HOURS ON NEXT PAGE Payroll pay period end date & hours covered by worker’s Comp check • EDB preparer must take two (2) separate actions • adjust the employee’s sick leave accruals (Coordinate w/Hospital Payroll)) • adjust the employee’s pay LX Transaction = Hours employee would have worked during the period covered by the Worker’s Comp check RX Transaction = Credit for the Worker’s Comp check WCR = DOS code used to report the amount of the Worker’s Comp check as a credit for the period of the check

42. Transaction Codes and Notifications Screen Label Data Name Data Values/Comments PTR Screen Tr Transaction Type Code Code indicating the nature of the transaction EDLR LX - Late Pay Used to report the sick leave and/or 80% ESL to be paid RX - Reduction in pay or leave Used to report the ORS check as a by-agreement credit Carbon Copy Recipients of ASAP: Payroll Notification and HR Benefits Team HR WC Cynthia Vazquez OPTIONAL Comments on the ASAP notification: EXAMPLES: “Employee on approved WC leave, Option 2 use of Sick Leave” “Employee has filed WC claim pending Approval. Extended Illness.” “Employee on 80% Extended Sick Leave under workers’ comp” “Extend WC LWOP. 80%ESL exhausted 05/30/03.”

43. SAMPLE #1 (OPTION 2) PPETLR-E1064 Dept. Adj Trans 11/08/01 08:45:02 11/05/01 23:51:40 Late/Reduce Pay (EDLR) Userid: MFLWO ID: 700486135 NAME: EXAMPLE, IMA SSN: 987-65-4321 Emp Status: A Pay End: 041302 Check Date: 042402 Pay Cycle: B2 Page 1 of 2 Seq: Tr: LX Per End: 033002 Pay Cy: B Dst: 11 E: E T: D: Ttl: 9252 LACFPS: 4 427980 63000 2 Rate: 13.5000 AH:H DOS: REG Time: 48.00 H%: H DOS: Hr: DOS: Hr: WSP: Seq: Tr: LX Per End:033002 Pay Cy: B Dst: 12 E: E T: D: Ttl: 9252 LACFPS: 4 427980 63000 2 Rate: .8500 AH: H DOS: SDFTime: 48.00 H%: H DOS: Hr: DOS: Hr: WSP: Seq: Tr: RX Per End: 040102 Pay Cy: B Dst: E:E T: D: Ttl: 9252 LACFPS: 4 427980 63000 2 Rate: 00720.00 AH: A DOS:WCR Time: H%: DOS: Hr: DOS: Hr: WSP: Payroll pay period end date & hours covered by worker’s comp Check Worker’s Comp check amount and end date of period covered

44. SAMPLE #1 (OPTION 2) PPETLR-E1064 Dept. Adj Trans 11/08/01 08:45:02 11/05/01 23:51:40 Late/Reduce Pay (EDLR) Userid: MFLWO ID: 700486135 NAME: EXAMPLE, IMA SSN: 987-65-4321 Emp Status: A Pay End: 041302 Check Date: 042402 Pay Cycle: B2 Page 2 of 2 Seq: Tr: LX Per End: 041302 Pay Cy: B Dst: 11 E: E T: D: Ttl: 9252 LACFPS: 4 427980 63000 2 Rate: 13.5000 AH:H DOS: REG Time: 8.00 H%: H DOS: Hr: DOS: Hr: WSP: Seq: Tr: LX Per End:041302 Pay Cy: B Dst: 12 E: E T: D: Ttl: 9252 LACFPS: 4 427980 63000 2 Rate: .8500 AH: H DOS: SDFTime: 8.00 H%: H DOS: Hr: DOS: Hr: WSP: Seq: Tr: Per End Pay Cy: Dst: E: T: D: Ttl: LACFPS: Rate: AH: DOS: Time: H%: DOS: Hr: DOS: Hr: WSP: Payroll pay period end date & hours covered by worker’s comp Check

45. SAMPLE #2 (OPTION 3) MISTER JONES - OPTION 3 Title: CN II (9139) Appointment: 90% (36 hr/wk, night shift) Salary: $29.51 hr/ + $4.00 NSD Injured: February 1, 2001 @ 3a.m. (sent to ER, taken off work) Sick Leave: 18 s/l and 24 v/l on date of injury ORS Check: $980.00 (February 2-15, 2001) $980.00 (February 16-March 1, 2001) Returned to Work: March 2, 2001

46. Add in the appropriate accruals based on Option 2 or 3!!! While at 100% pay, add in 100% accruals.

47. Not enough SL/VAC to complete worksheet! Contact Healthcare HR to change to 80%ESL.

48. NOTE REVISION DATE This balance is left in employee’s bank. Accruals while on 80%ESL will be added to this balance.

49. BEGIN and END dates of the 80% ESL benefit.

50. EDB Transaction for Employee on 80% Extended Sick Leave Page 1 of 2 ESL = DOS code for the 80% Extended Sick Leave period