To qualify for injury leave benefits an employee must meet two threshold requirements. These requirements relate to the employee’s position with the City, and the activity involved in at the time of the injury. The threshold requirements are described as follows:
Applicable Positions. Employees in the following class of positions meet the position threshold requirement:
1. Any full-time City employee whose job title and description meet the definition of law enforcement officer under U.C.A. 53-13-103 (1).
2. Any full-time City employee required and authorized to:
a. respond to a hazardous emergency situation to fight fires,
b. provide incident command,
c. conduct search and rescue activities,
d. provide disaster relief,
e. dispose of or contain hazardous materials,
f. provide emergency medical services, or
g. participate in high-hazardous fire drills or training.
Applicable Activities Employees involved in the following activities at the time of injury meet the activity threshold requirement.
1. The exercise of some form of necessary law enforcement authority.
2. The performance of emergency services including fire fighting, disaster response, search and rescue, hazardous materials response, emergency medical services, and incident command.
3. Department required high-hazard training or drills such as arrest and control, high hazard entry, search and rescue, and fire suppression.
Injury Leave benefits are secondary to any indemnity and wage replacement benefits provided by workers’ compensation, social security, disability, retirement benefits, or any form of governmental relief.
Notice Requirements
When an eligible injury occurs, an employee seeking injury leave benefits must complete and submit an Injury Leave Request Form to the Division of Risk Management. The request form should be turned in as soon as possible to avoid any disruption in pay.
Determination of Applicability
Upon receipt by the Division of Risk Management of an Injury Leave Request Form, the Risk Manager shall review the facts and circumstances of the injury, make a determination of the eligibility for Injury Leave benefits, and notify the employee in writing.
Employees may appeal the Risk Manager’s written decision of eligibility as stipulated in their applicable Memorandum of Understanding or Compensation Plan.
Termination of Benefits
Each Department shall track the injury leave benefit for its employees and shall advise the City’s Risk Manager when the per-injury benefit has reached $3,500 Upon receipt of such notice, the Risk Manager shall notify the injured worker of the estimated date upon which the maximum benefit will be reached. The injured employee will then be asked to elect an available alternate leave benefit or combination of available leave benefits to supplement the Temporary Total Disability benefit after the Injury Leave benefit has been exhausted.
If appropriate under the applicable Memorandum of Understanding or Compensation Plan, the employee may also request that the benefit limit be increased by written application to their Department Head.
Effective date: February 13, 2003
I, ________________________, hereby request injury leave benefits for time taken from work due to an industrial accident or injury that occurred on ____/____/______.
I understand that in order to receive Injury Leave benefits, my time away from work must be pre-approved by my medical provider and that I must qualify for Temporary Total Disability benefits under the Workers’ Compensation Laws of Utah. I further understand that Injury Leave benefits are designed to provide compensation up to my pre-injury net salary that Injury Leave benefits are secondary to any indemnity and wage replacement benefits provided by workers’ compensation, social security, disability, retirement benefits, or any form of governmental relief.
I declare that I am ____ /am not ____ receiving any other type of wage replacement or income benefits (other than workers’ compensation) and that I will fully disclose any such benefits to the City’s Risk Manager for use in determining appropriate Injury Leave benefits.
The department I work for is:
(Signature)
RETURN TO RISK MANAGEMENT, CITY & COUNTY BLDG., RM. 505
(or Fax 535-7640)
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Injury leave is approved ____/denied ____ by Risk Management (Date) Completed forms sent to Employee ¨ Payroll ¨ Workers’ Comp ¨ PPA ¨ |