Maryland Association Boards of Education
621 Ridgely Avenue, Suite 301
Annapolis, Maryland 21401
Phone: 410-841-2493 Fax: 410-841-2669
Employee's Statement of Injury
Supervisor's Incident Report Form
KCPS Personnel Procedure 300-14 Workers' Compensation Benefits
What to do in the event of work place accident/injury/illness:
- Report the incident immediately to your supervisor. You are responsible to complete the Employee Statement and your Supervisor completes the Supervisor’s Report. Both forms are located above. These two forms must be completed and submitted on the same day as the incident. Please submit to the Human Resources Department, attention: Bryn Kibler (scan to [email protected] or fax 410-810-2671).
- If medical treatment is needed, please be sure to tell the physician that your visit is for a work-related incident/injury/illness. Do not give them your health insurance card. In addition, do not fill your prescription by using your health insurance card.
- Do not use your health insurance for any visits to your physician. Instruct your physician’s office to send all medical bills directly to MABE at above address or fax.
- Following the doctor’s visit, you must contact either Bryn Kibler or Dan Hushion.
- If you have work restriction(s), you must contact Human Resources to see if we can accommodate your work restrictions and place you in the Return to Work program.
- After the initial visit, any further treatment or therapy should be scheduled outside of your work day.
- Please be sure to submit all doctors’ notes/reports to your supervisor and to Human Resources.
- Any missed time as a result of the injury must be authorized by your treating physician pursuant to Maryland workers compensation law. If you miss any time due to this injury, you must submit the documentation to your supervisor and to Human Resources. Workers’ Compensation does not pay for the first three (3) days of absence due to a workplace injury. This means the employee is responsible to cover these three days with their paid leave time.
- Any questions, contact Bryn Kibler at [email protected] or 410-778-3644.
Note: If the claim is not compensable under Workers Comp, the Payroll Office will adjust the employee’s leave according to the time lost and all medical bills will be denied by the workers compensation insurance carrier. Therefore, the employee will be responsible for forwarding the denied bills to his/her appropriate health care carrier. If care is received outside of your health care “network”, you could be responsible for expenses incurred.