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Return-to-Work Statement of Responsibilities

Supervisor is responsible for:

  • Obtaining immediate medical attention by in house medical staff if available.
  • Accompanying injured worker to medical provider, if at all possible, and tell the doctor about your company’s return-to-work process and provide the doctor with an explanatory letter.
  • Training employees on the proper reporting of incidents and injuries and return-to-work procedures.
  • Developing alternative assignments that will meet the doctor’s restrictions, that are meaningful, and ensuring that the injured employee follows these restrictions.
  • Ensuring prompt medical attention for the injured worker
  • Providing information to your company’s return-to-work coordinator.

Claims coordinator is responsible for:


  • Providing written policy statement and procedures, and making sure that the program is applied consistently. The program should be in compliance with the ADA, FMLA and the Texas Workers’ Compensation Act.
  • Ensuring or acting as the return-to-work coordinator who will take a proactive approach in the return-to-work program. Person will plan, lead, control, and monitor the return-to-work activities.
  • Providing SORM 85 to worker to give to treating doctor.
  • Providing injured employee’s job description to treating doctor.
  • Providing DWC-73 to worker to give to treating doctor.
  • Communicating regularly with the injured employee and the doctor after each follow up visit if off work.
  • Provide information to doctors to help them understand the employee’s regular job, the employer’s return-to-work program, and available work alternatives.
  • Sending Bona Offer letter certified to employee offering light duty assignment if doctor indicates modified duty.
  • Sending copy of Bona Offer letter and DWC-73 to SORM adjuster.
  • Act as the employer’s representative.
  • Maintain contact with the health care provider, the insurance company, the employee, and the employee’s supervisor.
  • Develop and maintain record keeping and reporting systems for incidents and injuries.

Reporting Injury

Complete SORM forms required to notify carrier of injury/incident:

  • DWC-1S First Report of Injury
  • DWC-3 Wage Statement
  • DWC-6 Supplemental Report
  • SORM-16 Medical Information Release
  • SORM-80 Election of Leave
  • SORM-29 Employee’s Report of Injury
  • SORM-74 Witness Statement

Employee is responsible for:

  • Understanding your company’s procedures for reporting injuries, and reporting any injury immediately to supervisor.
  • Informing treating doctor of alternative work availability and the return-to- work process. Give doctor SORM 85, DWC 73 and copy of job description.
  • If restricted for any type of work, notifying supervisor immediately, and if off work, at least once a week to let them know how you are doing.
  • Providing copy of DWC 73 to claims coordinator if doctor releases to restricted duty.
  • If a doctor releases you to work, return to work on the next scheduled shift.
  • If a doctor gives you medical restrictions for an alternative productive work assignment, follow the doctor’s orders.

Health Care provider is responsible for:

  • Providing immediate, appropriate, and effective treatment that facilitates recovery and expedited return to work.
  • Assessing the abilities of the injured employee, and provide the employee with physical restrictions to follow when performing job functions.
  • Providing information about the employee’s work capabilities to the employer and return-to-work coordinator.
  • Becoming familiar with operations at the employee’s workplace.
  • Completing and filing DWC-73 Work Status Report as required by the DWC.

SORM Adjuster responsibilities:

  • Determining if a offer of employment meets DWC rule.
  • If employee accepts bona fide offer and is earning pre injury wages, terminating workers’ compensation benefits.
  • If employee does not accept the offer, terminating workers’ compensation benefits.