NAF managers and supervisors are responsible for insuring that injured employees
receive prompt and fair medical treatment for any job related accident or injury.
The key to assuring that medical needs are fully accomplished and that employees
are compensated for any lost time and medical expenses is the timely and accurate
reporting of all injuries.
NAF employee injury claims are covered under the Longshore and Harbor Workers' Compensation
Act administered by the Department of Labor. Provisions of the Act cover
medical costs for the treatment, and benefits for disability or death resulting
from injury or occupational disease.
Simply stated, when an on-the-job accident results in injury:
- The injured employee or a representative is obliged to tell the facility manager
or supervisor when, where and how the injury occurred.
- The manager authorizes medical treatment for the employee, receives the doctor's
medical assessment, annotates how much work time the employee has lost due to the
injury and notifies the personnel office.
- The personnel office, in turn, notifies the Workmans' Compensation claims service
contractor, the Department of Labor and the Department of the Army (Army Central
To record each step in the Worker's Compensation process specific forms must be
completed. All required forms are listed below along with a short explanation
of who is to fill it out and what is to be done with the completed form. Additionally,
by clicking on the form you will be able to view and printed each of the required
forms. If difficulties in printing occur, you should contact your local NAF Civilian
Personnel Office for assistance in obtaining the required forms.
a. LS-1 - REQUEST FOR EXAMINATION OR TREATMENT
Part A of the LS-1 form is completed by the employee's supervisor and should be
given to the employee to take to the physician of their choice. The employee
should tell the supervisor where they plan to get treatment so this information
is entered on Part A, Number 2. In emergencies, first arrange for medical
care, then submit the LS-1. The medical facility or physician must complete Part
B of the LS-1 form is completed by the medical facility or doctor. (The claims service
contractor has prepared a German version of the LS-1 for use, as needed, when employees
receive medical treatment from German doctors or facilities. The German version
of the form is available at your local NAF Civilian Personnel Office.) The supervisor
may request a copy of the completed LS-1 from the employee. (NOTE: Injured employees
may use either American Military or German medical facilities, however, American
Military facilities will provide medical treatment without charge for the initial
visit if the employee is making a Workers' Compensation claim and presents the LS-1
Form to the cashier).
b. LS - 202 - EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL ILLNESS
The LS-202 form is completed by the employee's supervisor and is used by the claim
service contractor to establish a claim. The claim service contractor will
make all determinations of compensability. It is important that accurate work schedules
and salaries are reflected on the form and that all blocks on the form are filled.
This form must be forwarded to the NAF Personnel Office within 3 days of the injury.
c. LS - 204-ATTENDING PHYSICIAN'S SUPPLEMENTARY REPORT
The LS-204 form is completed when absence from work due to an on-the-job injury
extends over a long period of time. The employee is required to submit supplementary
progress reports prepared by their attending physician to the NAF Personnel Office
every 30 days, attesting to the employee's continuing disability, followed by a
final report attesting to the employee's recovery and ability to return to work.
Supervisors must insure that the injured employee receives a supply of these forms
and understands their responsibility in returning completed copies. The LS204
is also sent to the claim service contractor.
d. LS-210-EMPLOYER'S SUPPLEMENTARY REPORT OF ACCIDENT
The LS-210 form must be completed by the supervisor for each pay period of absence
from work (lost time) due to the injury followed by a final report attesting to
the employee's return to work on a full time basis. The supervisor gives these
completed reports to their local NAF Civilian Personnel Office.
e. LS-201 - NOTICE OF EMPLOYEE INJURY OR DEATH
The employee, or a representative, uses this form to describe the on-the-job injury
incident and request Workers' Compensation benefits. On the form, the employee describes
when, where, and how the injury occurred.
f. CLAIM BENEFIT OPTION ELECTION FORMAT
The Claim Benefit Option provides eligible injured employees the opportunity to receive
full pay (sick leave) for lost time while absent from work due to an on-the-job
injury, or to receive only the amount of temporary disability benefits that the
claims service contractor pays for lost time. If the employee elects to receive
full pay (sick leave) he/she agrees to assign, and endorse temporary disability
benefits checks issued by the claims service contractor over to the employment fund,
in effect, buying back sick leave hours used, equal to the amount of the temporary
disability benefits checks.