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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 7. EMPLOYMENT BENEFITS |
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Chapter 7-1. [DELETED] |
Section 7-108. EMPLOYEE NOTICE OF INJURY OR DEATH AND CLAIM FOR BENEFITS
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108.1An employee shall give notice of an injury, or an employee’s representative shall give notice of an employee’s death to the employee’s official superior within thirty (30) days of the injury or death, and all information that is required by section 2319 of the Act shall be supplied to the Program within that period.
108.2 Once the Program is notified by the official superior or by an employee of an employee’s injury or death, the Program shall forward by first-class mail or electronic mail the forms for making a claim for benefits to the employee or someone on the employee's behalf for review, revision, and execution.
108.3The employee shall provide all information required by the Program to make a determination on the claim.
108.4The Employee or his or her representative shall complete Form CA-7, Claim for Compensation, Part A, Employee Statement. The notice shall:
(a) Be in writing;
(b) State the name and address of the employee;
(c) State the year, month, day, and hour when, and the particular locality where, the injury or death occurred;
(d) State the cause and nature of the injury, or in the case of death, the employment factors believed to be the cause;
(e) State the employee's official job title, grade and step, and number of hours scheduled to work per day;
(f) State the employee's benefits deductions, if any, as listed in § 113 of this chapter;
(g) State whether a claim has been made against a third party as a result of the injury, disease, or death;
(h) State the names, relationship, and birth dates of employee's dependents, and the amount of support paid for dependents not living with the employee;
(i) Be signed by, and contain the address of, the individual giving the notice;
(j) In the case of the death of an employee, the individual filing the Form CA-7 shall provide documentation establishing the relationship to the deceased. Documentation may include :
(1) A certified copy of a birth certificate;
(2) A certified copy of a marriage license;
(3) Documentation of the executor of the employee’s estate; or
(4) Other documentation satisfactory to ORM.
(k) Have attached proof of dependency, if applicable, for example, birth certificates and court orders; and
(l) Have attached a copy of the employee's last pay stub.
108.5The employee shall complete a Medical Authorization and Release of Confidential Information and Earnings Data Form that ORM provides.
108.6The employee shall have his or her physician complete and return to the ORM a Form 3, Physician's Report of Employee's Injury, which shall state the nature and probable cause of the injury, including whether the injury was sustained while in the performance of the employee’s duties.
108.7 The employee shall submit proper medical documentation as requested by the ORM to support the employee's ongoing injury and absence from work. These documents shall include, but are not limited to, the following:
(a) Statements and medical documentation regarding any similar injury that occurred prior to the alleged injury or any pre-existing condition that may be related to the injury;
(b) Statements and medical documentation regarding any other injury or accident of a similar character; and
(c) A written statement showing why there was a delay in seeking medical care, if applicable.
108.8 The employee shall supply copies of the completed forms to the official superior for review and signature.
108.9The employee shall return the completed forms to the Program within thirty (30) days of the injury or death or within fifteen (15) days of the date from which the forms were mailed to the employee, whichever is later.
108.10The employee shall make supplemental reports when required by the Program or when any of the information that the employee provides the Program changes after it is initially submitted to the Program.
108.11The Program may require an employee to attend an orientation program regarding the requirements and processes of the Program before the employee may receive benefits under this chapter. Failure to attend the orientation may result in controversion of the employee’s claim, pursuant to § 111.4 or 112 of this chapter.