SECTION INDEX:    Injured Employees

1    Purpose

2    Reference

3    Application

4    Guidance

4.1    On the Job Injury

4.2    Serious Injury or Death

4.3    Employees

4.4    Supervisors

4.5    Human Resources

4.6    Third Party Administrator

4.7    Time Loss Compensation

5    Forms

5.1    Worker’s Compensation “Grey Packet” Sample

5.2    Return to Work Physical Capacity Evaluation (work related)

5.3    Return to Work Physical Capacity Evaluation (non-work related)

5.4    Employee Injury/Illness Report

5.5    Death or Critical Injury Procedures


The City wants to protect its employees from injury while working in their position (on the job) and to treat them fairly if they are injured on the job.


51.12.035; RCW 51.14, 51.32; WAC 296.15, 296.19, City of Olympia Policy-8 Employee Wellness


This Policy applies to all individuals employed by the City of Olympia, unpaid interns and volunteers injured in the performance of City functions, unless modified by contract or statute (e.g., civil service rules, union contract, individual employment contract or memorandum of understanding). If you sustain an injury because of an accident on the job, or an occupational disease because of the nature of your work for City, you should follow this Policy.

Failure to comply with this Policy may result in disciplinary action including termination from City service.


The City is self-insured for the purpose of Workers Compensation (WC) for employees injured on the job. This means that the City has its own WC program (that complies with the Washington State Labor and Industries guidelines).

4.1. On the Job Injury

An accident or occupational disease occurs when:

a.    The injury is a result of trauma (e.g. a physical wound or injury, such as a fracture or blow) that occurred while the employee was at work and completing the duties of their position);

b.    The injury occurred while performing required training for a City job;

c.    The injury occurred after a chemical, medical or workplace exposure;

d.    The injury arises as a disease or infection that arises naturally and proximately out of employment; or

e.    For Fire when the injury occurred within six (6) hours of a working fire response or other activity where a Self-Contained Breathing Apparatus (SCBA) was used by the employee;

If an employee is injured while at work in any of the ways described above, the employee should report the injury as a workplace injury to any treatment provider. The employee and his/her supervisor should fill out (or provide to his/her medical provider) all of the forms in the WC packet (the “grey packet”).

However, if something happens while the employee is at work that is not covered above (the employee feels ill, faint or physically sick) and the employee needs care from a medical provider, the employee should not report the event as a workplace injury. The employee should instead use his/her City insurance benefit (if a benefited employee) or other means to pay for the treatment by a medical provider of the employee’s choice (ambulance, emergency room, physician, tests). However, the employee and supervisor should still file an “Employee Injury/Illness Report” form for any medical issue that happens while at work.

4.2. Serious Injury or Death

In the event of a serious workplace injury (injury that is life threatening) or the workplace death of an employee, the supervisor is required to follow the directions contained in the media/forms/death-or-critical-injury-matrix.pdf" target="_blank">“Death or Life Threatening Injury Procedures”.

4.3. Employees

If an employee sustains an injury on the job they should:

a.    Seek emergency medical attention if necessary;

b.    Report the injury to their supervisor;

c.    Do his/her part to get well;

d.    Select a medical provider of your choice from the Labor and Industries medical network: www.FindADoc.Lni.wa.gov. The injured worker must get pre-approval from City’s third party administrator and/or HR before transferring care to a new provider or seeking a second medical opinion or consultation. Thoroughly follow all directions from his/her medical provider;

e.    Maintain communication with their supervisor; the City’s third party administrator; and HR; and

f.    Provide documentation as requested to their supervisor, and/or the City’s third party administrator and/or HR about their injury.

4.4. Supervisors

The supervisor should have access to the WC “Grey Packet”, which contains a variety of forms that need to be completed if medical attention is sought by the employee for treatment of the injury. The supervisor should:

a.    Ensure that an injured employee gets immediate medical treatment if necessary;

b.    Ensure that the injured employee completes the “Employee Injury/Illness Report” form;

c.    Complete the supervisor investigation of accident form;

d.    If the injured employee seeks medical treatment, he/she should ask their physician to fill out the Physician’s Initial Report (PIR, contained in the “grey packet”); the Physician portion of the SIF 2 claim form (contained in the “grey packet”); the Physical Capacity to Return to Work Form; and the appropriate (by Department) Light Duty Task List form;

e.    When the injured employee returns to work, the supervisor must make sure that the employee has had their Physician fill out the Physical Capacity to Return to Work Form and (if needed) the Light Duty Task List. The supervisor should send the forms onto Human Resources (HR);

f.    An injured employee (regardless of whether the injury occurred on or off duty) who is: 1) approved for light duty by his/her doctor; 2) the department has light duty available for the employee; but 3) she/he does not want to come in to do the light duty work must use vacation leave rather than sick leave because he/she is voluntarily deciding to stay away from work.

g.    In the case of life threatening injury or death, refer to the “Death or Life Threatening Injury Procedures” form.

4.5. Human Resources will

a.    Work with the injured employee (to the extent necessary) to assist he/she with the process and their recovery;

b.    Gather all of the forms about the injury and send them to the third party administrator;

c.    Assist the supervisor on any return to work issues;

d.    Provide wage and benefit information (working with Payroll) to the third party administrator; and

e.    Work with all parties to complete the claim.

4.6. The Third Party Administrator will

a.    Process the claim;

b.    Pay medical providers for services;

c.    Collaborate with City HR and Payroll to ensure proper payments (if any) to injured employees and to work on completing the claim.

4.7. Time-loss compensation payments (wage related replacement benefits)

a.    Employees receive a percentage of their regular wages if they are unable to work because of an injury or illness. Time-loss compensation payments range from 60-75 percent of the injured worker’s gross wage and benefits (depending on marital and dependent status).

b.    The employee does not receive time loss for the day of the injury or for the first three calendar days after the injury unless they are unable to work for 14 days from the date of the injury.

c.    The City will augment your time-loss payment with sick leave, floating holiday, comp time, and vacation leave in that order up to the amount of your full base salary.


5.1    Worker’s Compensation “Grey Packet” Sample

5.2    Return to Work Physical Capacity Evaluation (work related)

5.3    Return to Work Physical Capacity Evaluation (non-work related)

5.4    Employee Injury/Illness Report

5.5    Death or Critical Injury Procedures

Revision history: February 2017; May 2016; January 2015; March 2014; October 2013; Superseded: N/A