Fillable City of Waterbury Temporary Employee Policy Manual Acknowledgement (City of Waterbury, CT)

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City of Waterbury Temporary Employee Policy Manual Acknowledgement (City of Waterbury, CT)

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Rev. 3.7.19
City of Waterbury Temporary Employee
Policy Manual Acknowledgement
I (__________________________) hereby acknowledge receipt of the City of Waterbury Policy
Manual and orientation materials. By signing below, I agree to read these policies and materials
and abide by the terms and conditions contained therein.
I understand that if I have any questions about any policy, that I will contact the Human
Resources Department for clarification.
I further understand that my failure to comply with any of the City’s policies may subject me to
discipline, up to and including possible termination.
Signature: ________________________________________ Date: _______________
Notice of Electronic Monitoring
Electronic Mail Use Policy
Internet Policy
Executive Order #02-01 –Telephone Policy
Proper Work Attire Policy
Harassment in the Workplace Policy
Employee Assistance Program
Drug & Alcohol Policy
Gifts and Favors
Smoking Policy
Workers’ Compensation Pamphlet
Business & Legal Reports Safety Brochures: Reducing Risks, Safety
Attitude and Lifting
Waste, Abuse & Fraud Hotline
Nepotism
The City of Waterbury
And
Waterbury Board of Education
I, the undersigned employee of The City of Waterbury and Waterbury Board of
Education, have reviewed a copy of the City of Waterbury and Waterbury Board of
Education employer Medical Care Plan Requirements. I understand that failure to follow
the plan’s requirements may suspend my right to receive Workers’ Compensation benefits
subject to the order of a Workers’ Compensation Commissioner.
Print Name:
Employee Signature Date:
I have received a copy of the
“Payor and Medical Provider Guidelines to Improve the
Coordination of Medical Services”.
Employee Signature Date:
An employee who declines to return a completed and signed form
shall be considered to have accepted all statements as noted above.
The City of Waterbury
Department of Human Resources
Office of the Civil Service Commission
June 2020
Dear Summer Recreation staff:
You are being employed and entrusted with a most important position of
Leadership involving the care of children. This position allows you to make the
Recreation Programs a more meaningful and enjoyable experience for the children
who attend and use the playgrounds operated by the City of Waterbury Recreation
Department.
Your job is to provide an opportunity for the children attending: to learn, enjoy
and grow with the offered programs. Your enthusiasm and interaction, as well as
leadership and example will have a strong influence on the children that will guide
them and help them in their association with others throughout their lives.
Summer programs are a very memorable time for children, be sure to put forth
your best efforts in ensuring that these children have a great summer.
This manual is designed to inform you of the policies, programs and goals of the
City of Waterbury Recreation Department. Their success depends heavily on your
leadership, attitude and cooperation throughout the duration of the program.
Victor Cuevas, MS, ABO, CPO
Acting Superintendent of Recreation
SUMMER PLAYGROUND PERSONNEL
SCHEDULED WORKING HOURS:
1. Seasonal Staff: 9am-3pm, Monday-Friday
2. Permanent Staff: 8am-4pm, Monday-Friday
3. Staff members have a 20-minute lunch break, which is assigned by a Supervisor.
Lunch is to be taken on site unless otherwise arranged by a Supervisor.
4. If you are going to be late or out sick call your supervisor at the assigned location.
Chase: 574-8292, Washington: 574-8297 River-Baldwin: 574-8342
North-End: 574-8294
5. If you can’t reach anyone, call the Superintendent’s Office at: 203-574-8342 by
8:30am.
6. All summer staff must give their telephone number to a Supervisor by JUNE
25TH. The Supervisor will give a copy to the Superintendent of Recreation.
ATTENDANCE:
Daily worksheets with morning and afternoon attendance must be handed into the
Supervisor.
No parent or guardian is to take a child without the permission from the Supervisor.
Child also MUST be signed out on electronic system.
ATTIRE:
All staff must remember that they set an example for the children in the Summer
Program. Playground Leaders should keep a neat appearance and wear clean,
comfortable sports attire.
Sandals, bare feet, open toes are not allowed. Employees MUST wear City issued Staff t-
shirts. You will be sent home to change, with loss of pay. Shoes must be closed toe;
sneakers are preferred for safety reasons.
PAYROLL:
~ Payday is every two (2) weeks
~ Paychecks are issued on Thursday
~ All employees must sign a weekly worksheet
~ Site Supervisor sets up staff meetings, any questions should be directed to the site
Supervisor.
CONDUCT:
As an employee of the City of Waterbury Recreation Department, you are always
representing us, even when you do not have direct contact with the Public. As you work
in the park or at a pool, the Public is observing you. Your actions and behaviors affect
their perceptions of the City of Waterbury. Good Public service requires everyone to
perform his/her job in the most efficient, effective and courteous way possible. We want
our employees to be friendly, understanding, capable and willing to serve.
1. Look presentable, neat and clean.
2. Be courteous and sincere. Remember to smile; say “Please” and “Thank You.”
3. Be helpful when asked questions and always give accurate information. If you
don’t know the answer, say so, and find someone who can help or refer the person
to your immediate Supervisor.
4. Be firm and clear when interpreting rules. Don’t be sarcastic, rude or get into an
argument.
5. Stay calm and listen carefully to what you are being told. Call your immediate
supervisor if there is a problem you can’t solve or if you need help with an angry
person.
6. Most of all, if you do have to deal with an angry or rude member of the public,
don’t take it personally. Always give directions with a smile.
7. Be cooperative and nice, but limit your conversation to the problem or question at
hand. It is not your job to carry on personal conversations with the public
(because you need to get back to work.)
8. Drinking alcoholic beverages or use of any non-prescribed drug is strictly
prohibited while on duty. Any employee who reports for duty while under the
influence of non-prescribed drugs or alcohol is subject to discipline up to and
including termination.
9. Employees may not sleep or lounge while on duty. Employees may not lay down
on any of the benches or sleep or lay down in City vehicles.
10. Employees shall not use foul language or engage in fighting. This is grounds for
immediate termination.
11. Employees must notify your immediate supervisor of any conditions that may
affect your ability to perform your job.
12. Personal cell phones are NOT to be used while on City time. The ONLY time
the usage of a personal cell phone is permitted is on your break or emergency
situation.
13. If you are viewed talking or texting on your personal cell phone it will be
confiscated and given back to you at the end of the work day. You must keep
your attention on the children at all times.
Staff shall maintain professional and appropriate conduct in their daily interactions. It is
not appropriate for staff to engage in personal relationships or have physical contact
during work. You are reminded that you are subject to the City’s Sexual Harassment
policy. (Attached are copies of necessary polices for your review). Violations of these
conduct standards and/or City policies will result in immediate termination.
PERFORMANCE EVALUATIONS:
All seasonal employees will have their job performance evaluated by their immediate
supervisor. This evaluation helps employees perform their jobs better by indicating their
strengths and weaknesses. It also helps supervisors make decisions about future hiring.
RAIN DAY:
All staff must report to the site and will be reassigned to another location if
necessary.
ACCIDENTS/INCIDENTS:
Accident/Incident reports must be filled out and filed with the Supervisor immediately.
SAFETY PROCEDURES
1. If a child is seriously injured on site: get a supervisor, call 911 and the parents.
Do not move the child.
2. If you are in a situation where bodily fluids are present, make sure the person
aiding the injured is properly equipped with first aid equipment. Protective
gloves, clean area, 5 parts water to 1 part bleach.
3. All personnel must be made aware to call 911, you must dial 9 first then 911. Be
precise on the location of the victim. (Upper-park, lower-park, name of the street,
etc.)
4. Parents must be notified of ANY injury their child has received no matter how
small.
5. Incident/Accident reports must be filled out on any and every injury by the end of
that working day.
PROBITIED PRACTICES:
YOU ARE NOT TO TAKE ANY PICTURES OF THE
CHILDREN.
NO PICTURES OF THE CHILDREN ARE TO BE POSTED ON
FACEBOOK OR ANY OTHER SOCIAL MEDIA SITE.
IF YOU POST ANY PICTURES OR TAKE ANY PICTURES OF
THE CHILDREN, YOU WILL BE REPORTED TO HUMAN
RESOURCES FOR IMMEDIATE TERMINATION.
IN CONCLUSION:
The level of service provided to the citizens of the City of Waterbury is directly related to
your level of performance. As a public agency, we exist to provide services in the most
effective, productive and efficient way possible. The attitude and work ethic we display
while carrying out our duties plays a major role in determining the satisfaction level of
those we serve. Let’s work together and support one another so we can build the best
working teams possible.
Concussion History? Y ___ N___
Headache History? Y ___ N___
Developmental History
Psychiatric History
Previous # 1 2 3 4 5
Prior treatment for headache
Learning disabilities
Anxiety
Longest symptom duration
Days__ Weeks__ Months__ Years__
History of migraine headache
__ Personal
__ Family___________________
____________________
Attention-Deficit/
Hyperactivity Disorder
Depression
Sleep disorder
If multiple concussions, less force
caused reinjury? Yes__ No__
Other developmental
disorder_____________
Other psychiatric disorder
_____________
A. Injury Characteristics Date/Time of Injury Reporter: __Patient __Parent __Spouse __Other _____
1. Injury Description _____
_____
1a. Is there evidence of a forcible blow to the head (direct or indirect)? __Yes __No __Unknown
1b. Is there evidence of intracranial injury or skull fracture? __Yes __No __Unknown
1c. Location of Impact: __Frontal __Lft Temporal __Rt Temporal __Lft Parietal __Rt Parietal __Occipital __Neck __Indirect Force
2. Cause: __MVC __Pedestrian-MVC __Fall __Assault __Sports (specify) Other _____
3. Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? __ Yes __No Duration _____
4. Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? __ Yes __No Duration _____
5. Loss of Consciousness: Did you/ person lose consciousness? __ Yes __No Duration _____
6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __Answers questions slowly __Repeats Questions __Forgetful (recent info)
7. Seizures: Were seizures observed? No__ Yes___ Detail _____
F. Follow-Up Action Plan Complete ACE Care Plan and provide copy to patient/family.
___ No Follow-Up Needed
___ Physician/ Clinician Office Monitoring: Date of next follow-up
___ Referral:
___ Neuropsychological Testing
___ Physician: Neurosurgery____ Neurology____ Sports Medicine____ Physiatrist____ Psychiatrist____ Other
___ Emergency Department
© Copyright G. Gioia & M. Collins, 2006 v2
E. Diagnosis (ICD-10): __Concussion w/o LOC S06.0X0A __Concussion w/ LOC S06.0X1A __Concussion (Unspecified) S06.0X9A __Other (854)
__No diagnosis
ACE Completed by:______________________________ MD RN NP PhD ATC
PHYSICAL (10)
COGNITIVE (4)
SLEEP (4)
Headache
0 1
Feeling mentally foggy
0 1
Drowsiness
0 1
Nausea
0 1
Feeling slowed down
0 1
Sleeping less than usual
0 1 N/A
Vomiting
0 1
Difficulty concentrating
0 1
Sleeping more than usual
0 1 N/A
Balance problems
0 1
Difficulty remembering
0 1
Trouble falling asleep
0 1 N/A
Dizziness
0 1
COGNITIVE Total (0-4) _____
SLEEP Total (0-4) _____
Visual problems
0 1
EMOTIONAL (4)
Fatigue
0 1
Irritability
0 1
Sensitivity to light
0 1
Sadness
0 1
Sensitivity to noise
0 1
More emotional
0 1
Numbness/Tingling
0 1
Nervousness
0 1
PHYSICAL Total (0-10) _____
EMOTIONAL Total (0-4) _____
(Add Physical, Cognitive, Emotion, Sleep totals)
Total Symptom Score (0-22)
_____
Patient Name
DOB: Age:
Date: ID/MR#
ACUTE CONCUSSION EVALUATION (ACE)
Physician/Clinician Office Version
Gerard Gioia, PhD
1
& Micky Collins, PhD
2
1
Children's National Medical Center
2
University of Pittsburgh Medical Center
Exertion: Do these symptoms worsen with:
Physical Activity __Yes __No __N/A
Cognitive Activity __Yes __No __N/A
Overall Rating: How different is the person acting
compared to his/her usual self? (circle)
Normal 0 1 2 3 4 5 6 Very Different
D. RED FLAGS for acute emergency management: Refer to the emergency department with sudden onset of any of the following:
* Headaches that worsen * Looks very drowsy/ can’t be awakened * Can’t recognize people or places * Neck pain
*Seizures * Repeated vomiting * Increasing confusion or irritability * Unusual behavioral change
* Focal neurologic signs * Slurred speech * Weakness or numbness in arms/legs * Change in state of consciousness
A concussion (or mild traumatic brain injury (MTBI)) is a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical
forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural injury,
and is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). Concussion may or may not involve a loss of consciousness
(LOC). Concussion results in a constellation of physical, cognitive, emotional and sleep-related symptoms. Symptoms may last from several minutes to
days, weeks, months or even longer in some cases.
ACE Instructions
The ACE is intended to provide an evidence-based clinical protocol to conduct an initial evaluation and diagnosis of patients (both children and adults) with
known or suspected MTBI. The research evidence documenting the importance of these components in the evaluation of an MTBI is provided in the
reference list.
A. Injury Characteristics:
1. Obtain description of the injury - how injury occurred, type of force, location on the head or body if force transmitted to head. Different
biomechanics of injury may result in differential symptom patterns (e.g., occipital blow may result in visual changes, balance difficulties).
2. Indicate the cause of injury. Greater forces associated with the trauma are likely to result in more severe presentation of symptoms.
3/ 4. Amnesia: Amnesia is defined as the failure to form new memories. Determine whether amnesia has occurred and attempt to determine length of
time of memory dysfunction – before (retrograde) and after (anterograde) injury. Even seconds to minutes of memory loss can be predictive of
outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion
than is LOC (less than 1 minute).
1
5. Loss of consciousness (LOC) - If occurs, determine length of LOC.
6. Early signs. If present, ask the individuals who know the patient (parent, spouse, friend, etc) about specific signs of the concussion/ MTBI that may
have been observed. These signs are typically observed early after the injury.
7. Inquire whether seizures were observed or not.
B. Symptom Checklist:
2
1. Ask patient (and/ or parent, if child) to report presence of the four categories of symptoms since injury. It is important to assess all listed symptoms as
different parts of the brain control different functions. One or all symptoms may be present depending upon mechanisms of injury.
3
Record 1 for Yes or
0 for No for their presence or absence, respectively.
2. For all symptoms, indicate presence of symptoms as experienced within the past 24 hours. Since symptoms can be present premorbidly/at baseline
(e.g., inattention, headaches, sleep, sadness), it is important to assess change from their typical presentation.
3. Scoring: Sum total number of symptoms present per area, and sum all four areas into Total Symptom Score (score range 0-22). (Note: most sleep
symptoms are only applicable after a night has passed since the injury. Drowsiness may be present on the day of injury.) If symptoms are new and
present, there is no lower limit symptom score. Any score > 0 indicates positive symptom history.
4. Exertion: Inquire whether any symptoms worsen with physical (e.g., running, climbing stairs, bike riding) and/or cognitive (e.g., academic studies,
multi-tasking at work, reading or other tasks requiring focused concentration) exertion. Clinicians should be aware that symptoms will typically worsen or
re-emerge with exertion, indicating incomplete recovery. Over-exertion may protract recovery.
5. Overall Rating: Determine how different the person is acting from their usual self. Circle 0 (Normal) to 6 (Very Different).
C. Risk Factors for Protracted Recovery: Assess the following risk factors as possible complicating factors in the recovery process.
1. Concussion history: Assess the number and date(s) of prior concussions, the duration of symptoms for each injury, and whether less biomechanical
force resulted in re-injury. Recent research indicates that cognitive and symptom effects of concussion may be cumulative, especially if there is minimal
duration of time between injuries and less biomechanical force results in subsequent concussion (which may indicate incomplete recovery from initial
trauma).
4-8
2. Headache history: Assess personal and/or family history of diagnosis/treatment for headaches. Recent research indicates headache (migraine in
particular) can result in protracted recovery from concussion.
8-11
3. Developmental history: Assess history of learning disabilities, Attention-Deficit/Hyperactivity Disorder or other developmental disorders. Recent
studies indicate the possibility of a longer period of recovery with these conditions.
12
4. Psychiatric history: Assess for history of depression/mood disorder, anxiety, and/or sleep disorder.
13-16
D. Red Flags: The patient should be carefully observed over the first 24-48 hours for these serious signs. Red flags are to be assessed as possible signs
of deteriorating neurological functioning. Any positive report should prompt strong consideration of referral for emergency medical evaluation (e.g. CT
Scan to rule out intracranial bleed or other structural pathology).
17
E. Diagnosis: The following ICD-10 diagnostic codes may be applicable.
S06.0X0A (Concussion, with no loss of consciousness) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a);
plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture
or intracranial injury (A1b).
S06.0X1A (Concussion, with brief loss of consciousness < 30 minutes) - Positive injury description with evidence of forcible direct/ indirect blow to
the head (A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); positive evidence of
LOC (A5), skull fracture or intracranial injury (A1b).
S06.0X9A (Concussion, unspecified) - Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus evidence of
active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC
(A5), no skull fracture or intracranial injury.
Other Diagnoses – If the patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A
1b) such as from neuroimaging, a moderate TBI and the diagnostic category of S06.890A (Intracranial injury) should be considered.
F. Follow-Up Action Plan: Develop a follow-up plan of action for symptomatic patients. The physician/clinician may decide to (1) monitor the patient in the
office or (2) refer them to a specialist. Serial evaluation of the concussion is critical as symptoms may resolve, worsen, or ebb and flow depending upon
many factors (e.g., cognitive/ physical exertion, comorbidities). Referral to a specialist can be particularly valuable to help manage certain aspects of the
patient’s condition. (Physician/clinician should also complete the ACE Care Plan included in this tool kit.)
1. Physician/clinician serial monitoring- Particularly appropriate if number and severity of symptoms are steadily decreasing over time and/or fully
resolve within 3-5 days. If steady reduction is not evident, referral to a specialist is warranted.
2. Referral to a specialist – Appropriate if symptom reduction is not evident in 3-5 days, or sooner if symptom profile is concerning in type/severity.
Neuropsychological Testing can provide valuable information to help assess a patient’s brain function and impairment and assist with treatment
planning, such as return to play decisions.
Physician Evaluation is particularly relevant for medical evaluation and management of concussion. It is also critical for evaluating and managing
focal neurologic, sensory, vestibular, and motor concerns. It may be useful for medication management (e.g., headaches, sleep disturbance,
depression) if post-concussive problems persist.
Name: Birth Date: Date:
Parent/Guardian Phone #’s: Provider Phone #:
Fax #:
(or stamp)
Important! Things that make your asthma worse (Triggers): ☒ smoke ☐ pets ☐ mold ☐ dust
☐ tree/grass/weed pollen ☐ colds/viruses ☐ exercise ☐ seasons: other:
Severity Classification: ☐ Severe Persistent ☐ Moderate Persistent ☐ Mild Persistent ☐ Intermittent
Make an appointment with your primary care provider within two days of an emergency visit, hospitalization, or anytime for ANY problem or question with asthma
SchoolNurse:Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
Parents: Call your doctor for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
H
EALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Parent/Guardian Consent: REQUIRED
I authorize this medication to be administered by school personnel OR I authorize the student to possess and self-administer medication.
I also authorize communication between the prescribing health care provider, the school nurse, the school medical advisor and school-based clinic providers necessary for
asthma management and administration of this medication.
Parent/Guardian Signature: ____________________________________ Date: _____________ * Bring asthma meds and spacer to all visits
You have any of these:
First signs of a cold
Exposure to known trigger
Cough
Wheeze
Tight chest
Coughing at night
Your asthma is
getting worse fast:
Medicine is not helping
Breathing is hard and fast
Nose opens wide
Can’t talk well
Getting nervous
GO – You’re Doing Well! USE THESE MEDICINES EVERY DAY TO PREVENT SYMPTOMS
CAUTION – Slow Down! Continue with Green Zone Medicine and Add:
DANGER
–
Get Hel
p
! TAKE THESE MEDICINES
A
ND SEE
K
MEDICAL HELP NOW!
You have all of these:
Breathing is good
No cough or wheeze
Sleep through
the night
Can work
and play
CONTROLLER MEDICINE DIRECTIONS
___________________________________ ______________________________________
___________________________________ ______________________________________
☐Ifyourchildusuallyhassymptomswithexercisethengive:
___________________________________ ______________________________________
Inhalers work better with spacers. Always use with a mask when prescribed.
RESCUE MEDICINE DIRECTIONS
___________________________________________________________________________
Then:Wait20minutesandseeifthetreatment(s)helped
IfyouareGETTINGWORSEorNOTIMPROVINGafterthetreatment(s)GOTOREDZONE
IfyouareBETTER,continuetreatmentsevery4to6hoursasneededfor24to48hours
Then: Ifyoustillhavesymptomsafter24hours,CALLYOURDOCTORandifhe/sheagrees:
Start:
________________________________________________________________
Ifrescuemedicationisneededmorethan2timesaweek,callyourdoctorat:_______________________
RESCUE MEDICINE DIRECTIONS
_____________________________________________________________________________
Then: Wait15minutesandseeiftreatmenthelped
IfGETTINGWORSEorNOTIMPROVING,gotothehospitalorcall911
IfyouaregettingBETTER,continuetreatmentsevery4to6hoursandcallyourdoctor–sayyouare
havinganasthmaattackandneedtobeseenTODAY
!
Then: Ifyourdoctoragrees,start:_________________________________________________
Peak Flow may be useful
for some kids.
Asthma Action Plan
Ages 0 – 11 Years
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
This form is not in compliance with CT DPH Daycare Licensing regulation 19a-79-9a, and Section 19a-79-9a
Administration of Medications, Order From an Authorized Prescriber/Parent's Permission
PRINT
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
www.ct.gov/dph/asthma
Nombre de paciente: Fecha de nacimiento: Fecha:
# teléfono del Padre/Guardián: # teléfono del Médico:
# fax:
¡Importante! Cosas que hace peor el asma: □ humo □ mascotas □ moho □ polvo
□ polen de árbol/hierba □ resfriado/virus □ ejercício □ cambio de clima: □ otras cosas:
Clasificación de Severidad: □ Severo persistente □ Moderado persistente □ Leve persistente □ Leve Intermitente
Haga una cita con su proveedor de cuidado primario dentro de dos días a partir de una visita al ED o una hospitalización, o en cualquier momento para cualquier
problema o pregunta sobre asma.
SchoolNurse:Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms
Padre/Guardián: Llame al médico para discutir preguntas sobre control del asma o si uso de medicina de rescate es más que 2 veces/semana
H
EALTHCARE PROVIDER SCHOOL MEDICATION AUTHORIZATION REQUIRED FOR ___________________as stated in accordance with CT State Law and Regulations 10-212a
Self–Administration: This student is capable to safely and properly self-administer this medication OR This student is not approved to self-administer this medication
Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______
Padre/Guardián: OBLIGATARIO
Autorizo al empleados medicos de la escuela para dar estas medicinas a mi niño/a O Autorizo al estudiante para tener estas medicinas y tomárselas a si mismo
Autorizo también la comunicación, entre el médico que prescribe las medicinas, la enfermera escolar, el consejero médico escolar, y professionales de clínica basados en la
escuela que es necesario para el manejo de asma y administración de estas medicinas.
Firma del Padre/Guardián: ___________________________ Fecha: _____________ Traiga medicinas para asma y espaciador a todas citas.
Rápidamente, su asma
está empeorando:
La medicina no le ayuda
Respiración es difícil y rápido
Las fosas nasales se abre ancha
No puede hablar bien
Se
p
one nervioso
Si tiene estos sintomas:
Síntomas iniciales del resfriado
Contacto con alguna cosa que
provoca asma
Tos
Sibilancia
Pecho apretado
Tos por la noche
Usted tiene todos estos
sintomas:
Respira bien
No hay tos o sibilancias
Duerme toda la noche
Puede trabajar y jugar
Proceda – ¡Está haciendo bien! USE ESTAS MEDICINAS CADA DÍA PARA PREVENIR SÍNTOMAS
PRECAUCIÓN – ¡Detengase! Continúe con medcina de la Zona Verde y Añade:
MEDICINA DE CONTROL COMO DEBERÍA TOMARLA
___________________________________ ______________________________________
___________________________________ ______________________________________
☐SiporlogeneralsuniñotienesÍntomasdeasmaduranteelejercicio,déle:
___________________________________ ______________________________________
Inhaladores funciona mejor con un espaciador.
Siempre use con el espaciador con mascarilla o boquilla.
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
___________________________________________________________________________
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Empiece:________________________________________________________________
Sinecesitamedicinaderescatemásquedosvecesenunasemana,llameasumédico:_________________
MEDICINA DE RESCATE COMO DEBERÍA TOMARLA
_____________________________________________________________________________
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Información sobre flujo máximo
podría ser útil para niños que no
perciben bien sus síntomas.
Plan de Acción Contra el Asma
Niños 0 – 11 años
PELIGRO
–
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Obten
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a a
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A
SYCOJA
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YUDA MEDICA AHORA MISMO!
■
FIRST AID FOR SEIZURES
First aid for seizures involves responding in ways that can keep the person safe until the seizure
stops by itself. Here are a few things you can do to help someone who is having a generalized tonic-
clonic (grand mal) seizure:
Keep calm and reassure other people who may be nearby.
Prevent injury by clearing the area around the person of anything hard or sharp.
Ease the person to the floor and put something soft and flat, like a folded jacket, under his/her
head.
Remove eyeglasses and loosen ties or anything around the neck that may make breathing
difficult.
Time the seizure with your watch. If the seizure continues for longer than 5 minutes without
signs of slowing down or if a person has trouble breathing afterwards, appears to be injured, in
pain or recovery is unusual in some way, call 911.
Do not hold the person down or try to stop movements.
Contrary to popular belief, it is not true that a person having a seizure can swallow their
tongue. DO NOT put anything in the person’s mouth. Efforts to hold the tongue down can
injure the teeth or jaw.
Turn the person gently onto one side. This will help keep the airway clear.
Don’t attempt artificial respiration except in the unlikely event that a person does not start
breathing again after the seizure has stopped.
Stay with the person until the seizure ends naturally and he/she is fully awake.
Do not offer the person water or food until fully alert.
Be friendly and reassuring as consciousness returns.
Offer to call a taxi, friend or relative to help the person get home if they seem confused or
unable to get home without help.
Here are a few things you can do to help someone who is having a seizure that appears as blank
staring, loss of awareness, and/or involuntary blinking, chewing, or other facial movements.
Stay calm and speak reassuringly.
Guide him/her away from dangers.
Block access to hazards, but don’t restrain the person.
If the person is agitated, stay a distance away, but close enough to protect until full awareness
has returned.
CONSIDER A SEIZURE AN EMERGENCY AND CALL 911 IF ANY OF THE FOLLOWING OCCURS:
The seizure lasts longer than 5 minutes without signs of slowing down or if a person has
trouble breathing afterwards, appears to be in pain or recovery is unusual in some way.
The person has another seizure soon after the first one
The person cannot be awakened after the seizure activity has stopped.
The person became injured during the seizure.
The person becomes aggressive
The seizure occurs in water.
The person has a health condition like diabetes or heart disease or is pregnant.
Name: _________________________________________________________________________ D.O.B.: ____________________
Allergy to: __________________________________________________________________________________________________
Weight: ________________ lbs. Asthma: □ Yes (higher risk for a severe reaction) □ No
PLACE
PICTURE
HERE
1. Antihistamines may be given, if ordered by a
healthcare provider.
2. Stay with the person; alert emergency contacts.
3. Watch closely for changes. If symptoms worsen,
give epinephrine.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2018
1. INJECT EPINEPHRINE IMMEDIATELY.
2. Call 911. Tell emergency dispatcher the person is having
anaphylaxis and may need epinephrine when emergency
responders arrive.
• Consider giving additional medications following epinephrine:
» Antihistamine
» Inhaler (bronchodilator) if wheezing
• Lay the person flat, raise legs and keep warm. If breathing is
difficult or they are vomiting, let them sit up or lie on their side.
• If symptoms do not improve, or symptoms return, more doses of
epinephrine can be given about 5 minutes or more after the last dose.
• Alert emergency contacts.
• Transport patient to ER, even if symptoms resolve. Patient should
remain in ER for at least 4 hours because symptoms may return.
HEART
Pale or bluish
skin, faintness,
weak pulse,
dizziness
MOUTH
Significant
swelling of the
tongue or lips
OR A
COMBINATION
of symptoms
from different
body areas.
LUNG
Shortness of
breath, wheezing,
repetitive cough
SKIN
Many hives over
body, widespread
redness
GUT
Repetitive
vomiting, severe
diarrhea
NOSE
Itchy or
runny nose,
sneezing
MOUTH
Itchy mouth
SKIN
A few hives,
mild itch
GUT
Mild
nausea or
discomfort
THROAT
Tight or hoarse
throat, trouble
breathing or
swallowing
OTHER
Feeling
something bad is
about to happen,
anxiety, confusion
Epinephrine Brand or Generic: ________________________________
Epinephrine Dose: □ 0.1 mg IM □ 0.15 mg IM □ 0.3 mg IM
Antihistamine Brand or Generic: _______________________________
Antihistamine Dose: __________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): __________________
____________________________________________________________
MEDICATIONS/DOSES
SEVERE SYMPTOMS
MILD SYMPTOMS
FOR MILD SYMPTOMS FROM MORE THAN ONE
SYSTEM AREA, GIVE EPINEPHRINE.
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM
AREA, FOLLOW THE DIRECTIONS BELOW:
FOR ANY OF THE FOLLOWING:
NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following allergens: _________________________________________________________
THEREFORE:
□ If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
□ If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF
ADRENACLICK
®
), USP AUTO-INJECTOR, IMPAX LABORATORIES
1. Remove epinephrine auto-injector from its protective carrying case.
2. Pull off both blue end caps: you will now see a red tip.
3. Grasp the auto-injector in your fist with the red tip pointing downward.
4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.
5. Press down hard and hold firmly against the thigh for approximately 10 seconds.
6. Remove and massage the area for 10 seconds.
7. Call 911 and get emergency medical help right away.
HOW TO USE EPIPEN
®
AND EPIPEN JR
®
(EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION
(AUTHORIZED GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN
1. Remove the EpiPen
®
or EpiPen Jr
®
Auto-Injector from the clear carrier tube.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds.
7. Call 911 and get emergency medical help right away.
OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2018
EMERGENCY CONTACTS — CALL 911
RESCUE SQUAD: ______________________________________________________________________
DOCTOR: _________________________________________________ PHONE: ____________________
PARENT/GUARDIAN: ______________________________________ PHONE: ____________________
OTHER EMERGENCY CONTACTS
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.
ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
1. Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer
thigh. In case of accidental injection, go immediately to the nearest emergency room.
2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
3. Epinephrine can be injected through clothing if needed.
4. Call 911 immediately after injection.
HOW TO USE AUVI-Q
®
(EPINEPRHINE INJECTION, USP), KALEO
1. Remove Auvi-Q from the outer case.
2. Pull off red safety guard.
3. Place black end of Auvi-Q against the middle of the outer thigh.
4. Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.
5. Call 911 and get emergency medical help right away.
3
5
3
4
WOOD SMOKE, STRONG
ODORS, & SPRAYS
These can reduce air quality and irritate airways.
• Avoid inhaling smoke from burning wood.
• Avoid strong odors and sprays, like perfume, powders, hair spray, paints, incense,
cleaning products, candles, and new carpeng.
OTHER TRIGGERS
Cold air, changes in weather, and strong
emotions can set o an asthma attack.
• Cover your nose and mouth with a scarf when it gets cold.
• Somemes laughing or crying can be a trigger.
• Some medicines and foods can trigger asthma.
MICE, RATS, &
COCKROACHES
Some people are allergic to the droppings
from these pests.
• Seal openings, cracks, and crevices.
• Do not leave food or garbage uncovered.
• Clean up spills and food crumbs right away.
• Store food in airght containers and cooking grease in the refrigerator.
• Keep food out of the bedroom.
WHAT YOU CAN DO TO REDUCE YOUR TRIGGERSTRIGGERS
www.health.state.mn.us/asthma health.asthma@state.mn.us
• Do not allow smoking or vaping in your home or car, or around you.
• Talk to your health care provider about quing or call: 1-800-QUIT-NOW (800-784-8669)
to connect to a Quitline coach. Free tools are available at www.quitplan.com
• Get special dust mite-proof covers for your pillows and maresses.
• Wash sheets and blankets in hot water every week.
• Wash stued animals frequently and dry completely.
• Use a high quality furnace lter.
• Avoid having carpeng, if you can, or vacuum weekly with a HEPA vacuum cleaner.
TOBACCO SMOKE
Tobacco smoke can make asthma worse.
ANIMALS
Some people are allergic to skin flakes (dander),
urine, or saliva from animals and birds.
• Keep pets with fur or feathers out of your home.
• If you can’t keep a pet outdoors, then keep the pet out of your bedroom, and keep
the bedroom door closed.
• Keep pets o upholstered furniture and away from stued toys.
• Wash your hands aer peng or playing with pets.
COLDS, FLU, & BRONCHITIS
When you’re sick, your asthma is more likely
to flare up.
• Wash your hands oen.
• Don’t touch your eyes, nose, or mouth.
• Get a u shot every year, preferably in the fall.
• Avoid contact with people who have colds.
• Try to keep your windows closed during pollen season and when mold counts are high.
• Plan to do indoor acvies on high pollen days.
• Ask your health care provider about taking medicine during allergy season.
• Follow daily air quality forecasts at www.pca.state.mn.us/air/current-air-quality
POLLEN & OUTDOOR
AIR POLLUTION
Some people are allergic to molds or pollen
from trees, grass, and weeds.
DUST MITES
Tiny spider-like mites live in cloth, carpet,
and bedding and are too small to see with
the naked eye.
INDOOR MOLD
This can be a trigger if your home has
high moisture.
• Fix leaking faucets, pipes, or other sources of water within 24 hours.
• Clean moldy surfaces with hot water and soap.
• Use bath and kitchen exhaust fans.
• Use a dehumidier in the basement if it is damp and smelly.
EXERCISE OR SPORTS
This can trigger an asthma attack for
some people.
• Take your rescue medicine before sports or exercise to prevent symptoms if directed
by your health care provider.
• Warm up/cool down for 5-10 minutes before and aer sports or exercise.
ASTHMA
TRIGGERS
Triggers are things that make your asthma worse. Some triggers are things
you are allergic to and some just irritate your airways. You can reduce how
often your asthma flares up by reducing exposure to your triggers.
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The City of Waterbury
Connecticut
NOTICE – Electronic Monitoring
Pursuant to the authority of Connecti
cut General Statue Section 3l‐48d, the City of Waterbury
hereby gives notice to all its employees of the potential use of electronic monitoring in its
workplace. While the City of Waterbury may not actually engage in the use of electronic
monitoring, it reserves the right to do so when determined by the City of Waterbury
in its
discretion.
''Electronic monitoring," as defined by Connecticut General Statue Section 3l‐48d, means the
collection of information on City of Waterbury's: premises concerning employees' activities or
communications, by any means other than direct observation of the employees. Electronic
monitoringin
cludestheuseofacomputer,telephone,wire,radio,camera,electromagnetic,photo‐
electronic or photo‐optical systems. The law does not cover the collection of information (A) for
security purposes in any common areas of the City of Waterbury's premises which are open the
publicor(B)which is prohibitedunderotherstateorfederallaw
.∙
ThefollowingspecifictypesofelectronicmonitoringmaybeusedbyCityofWaterbury
Initsworkplace(s).
Monitoring of e‐mail and other components of City of Waterbury's computer system for
compliancewithpolicies.
Videosurveillanceofemployeeparkingareasforsecuritypurposes.
Monitoringofelectromagneti
ccar
daccesssystemforsecuritypurposes.
The law also provides that City of Waterbury may use electronic monitoring without any prior
notice when City of Waterbury has reasonable grounds to believe employees are engaged in
conduct that (i) violates the law, (ii) violates the legal rights of City of Waterbury or other
employees, or (iii) create
s a hostile work environment and electronic monitoring may produce
evidenceofsuchconduct.
Questionsaboutelectronicmonitoring intheworkplaceshouldbedirectedtotheHumanResource
Departmentat(203)574‐6761.
CHAPTER39:ETHICSANDCONFLICTSOFINTEREST
(E)Nepotisminmunicipalemployment.
(1)TheCityofWaterburyanditsemployeesshalladheretothehighestethicalstandardsand
shall avoid unmerited favoritism toward relatives. This policy shall not be construed to unnecessarily
excludequalifiedapplicantsfrommunici palemployment.
(2)The city shall recruit and se
l
ectemployees based upon their qualifications and merit, and
the city's requirements.City officials, department heads and management employees shall not
participate in or influence employment decisions directlyaffectingtheir relatives, but may participate
indecisions affectingtheirrelativesas members of broadgroupsorclasses of employees.Relativesof
city officials, department heads or m
anagement employees shall be hired, transferred or promoted
only after disclosure to the Human Resource Director, and approval by the Civil Service Commission
pursuanttodivision(E)(5)(b)below.
(3)Unless disclosed to the Human Resources Director, and approved by the Civil Service
Commissionpursuant todivision(E)(5
)below, nopersonwillbe hired,promotedortransferred intoa
departmentinwhicharelativeisemployedif:
(a) The relative occupies a position in the supervisory hierarchy under which the person
wouldwork,and
(b)Therelativecouldinfluenceemploymentandpersonneldecisionsaffectingtheperson.
(4)For purposes of this division (E
), the term RELATIVE means spouse, parent, grandparent,
child,grandchild,brother,sister,aunt,uncle,niece,nepheworcor r espondingin‐lawor"step"relation.
(5)Employeesshalldisclosesituationsthatconflictwiththeconditionsstatedindivision(E)(3)
abovetotheHumanResourcesDirectorwithin15calendardaysofoccurrence.
(a)Thefollowingeventsmustbereportedunder thisdivision:
1) Ifemployeesbecom
e relativesbymarriageoradoption during the courseof their
employment,thenthemarriageoradoptionisareportableevent.
2) The acceptance of an offer of employment, including voluntary or involuntary
transferorpromotion, thatconflictswith the conditionsstatedin division(E)(3) aboveisa reportable
event.
(b) Within 15 days after receipt of disclosure pursuant to this division (E)(
5),The Human
Resources Director shall notify the appointing authority of the affected employees and direct the
appointingauthorityto draftanemploymentplan addressingtheconflict.Thedraft employmentplan
shall be submitted to the Civil
Service Commission by the appointing authority within 30 days of the
appointing authority's notification by theHumanResources Director. Within30days after submission
thereto, the Civil Service Commission shall review the draft employment plan and may recommend
amendments as it deems appropriate. The Civil Service Commission can either approve the plan or
amende
dplan,ordenytheplanoramendedplan.Anapproved employment planshall beimmediately
implemented if the Civil Service Commission denies the plan or the amended plan, the Civil Service
Commissionshallpromulgateanemploymentplanaddressingtheconflict, whichshallbeimmediately
implemented. If the Civil Service Commission has taken no action more than 30 days after it was
submitted,thedraftemploymentplansubmi
ttedbytheappointingauthorityisapprovedbydefault.
(c) Notwithstanding a conflict with divisions (E)(2) or (3) above, a person may be
conditionallyhired,promotedortransferredintoadepartm entinwhicharelativeisemployed
priorto
theapproval oftheemployment planby theCivil ServiceCommission,providedaproperdisclosureis
made to the Director of Human Resources, and conditioned upon compliance the plansubsequently
approvedbytheCivilServiceCommission.
(d) The failure ofanemployee to reportareportable event asrequired by this divisionis
grounds for discipl
inary action, including involuntary transfer, reassignment, or termination of
employment.
A GOODATTITUDE
For Safety Means Being•••
Attentive to safety training and safety talks
Eager to understand workplace procedures and
asking questions about anything not understood
Alert for anything that doesn't "feel" right and
anything that could go wrong-before a job is started
Careful, taking precautions and wearing protective clothing and
equipment
Focused on the job
Team-oriented and using the buddy system for hazardous tasks.
Serious about safety – never fooling around on the job!
Fooling around is
for FOOLS!
Lew and Sandy were bored and
started playing catch with their
tools. They didn't stop to think
about what might go wrong.
Unfortunately, Lew missed.
Another worker was hit-and
injured.
2005-29
The MCMC CareSys
Workers’ Compensation Medical Care Plan
City of Waterbury
and
Waterbury Board of Education
EFFECTIVE DATE OF PLAN IS:
SEPTEMBER 15, 2016
REVISED DATE:
JANUARY 1, 2019
APRIL 1, 2019
Prepared for:
PMA Management Corp. of New England
101 Barnes Road
Suite 300
Wallingford, CT 06492
City of Waterbury and Waterbury Board of Education
Medical Care Plan
To All Employees:
The City of Waterbury and Waterbury Board of Education has elected to become a participating employer
in an Employers Medical Care Plan filed with the Connecticut Workers’ Compensation Commission. The
Employer Medical Care Plan allows The City of Waterbury and Waterbury Board of Education to direct
employees to a list of Medical Providers for treatment of work-related injuries and illnesses. Failure to do
so may suspend an employee’s right to receive Workers’ Compensation benefits, subject to the order
of a Worker’s Compensation Commissioner.
The City of Waterbury and Waterbury Board of Education Employer Medical Care Plan is part of The
MCMC CareSys Medical Care Plan and of PMA Management Corp. of New England, the employer’s
risk management firm. The effective date of the Employers Medical Care Plan is September 15, 2016. The
current revised date is effective April 1, 2019.
The City of Waterbury and Waterbury Board of Education Workers’ Compensation medical care plan is
applicable for injuries occurring on or after the plan’s effective date. If you have an established and approved
Workers’ Compensation claim and are currently being treated for that injury, there are no changes. You can
continue your treatment with your established treating provider until treatment for your injury is completed.
As an employee of The City of Waterbury and Waterbury Board of Education, you must report a work-related
injury or illness to your supervisor, who will complete a First Report of Injury Form before the end of the
shift. If you require medical intervention or evaluation for your injury or illness, you will be directed to your
choice from a primary care center to receive treatment. If you require further medical treatment, notify your
department supervisor. If you have a medical emergency, go to the nearest emergency department.
You may obtain follow-up medical care from providers listed on The MCMC CareSys Medical Care Plan
directory, which is available through Risk Management. Should your injury require specialty treatment not
available in The MCMC CareSys Medical Care Plan, a consultant from an approved list established by the
Workers’ Compensation Commission may be chosen for your treatment. Please see The City of Waterbury’s
Risk Manager for guidance.
Please review the medical care plan guide, and sign the Employee Acknowledgment, recognizing your
understanding and that you have read and understand the process for treatment of work-related injuries or
illnesses.
If you are out of work as a result of your work-related injury or illness, you will be contacted regularly
by the PMA Management Corp. of New England Claims Coordinator to determine that your medical
needs are met. You are responsible for providing on-going updates regarding your work status to your
supervisor. Each of you is an important member of The City of Waterbury and Waterbury Board of
Education and the purpose of this program is to ensure you receive appropriate medical treatment in a timely
manner to facilitate recovery. If you have any questions during this process, please contact Risk Management
at 1-203-574-6840.
The Management staffs of The City of Waterbury and Waterbury Board of Education, PMA Management
Corp. of New England, and MCMC CareSys llc are available to assist you from the time of your injury
through recovery and return to work.
QUESTIONS ABOUT WORKERS’ COMPENSATION
You May Ask About Workers’ Compensation Protection.
1. What is Workers’ Compensation?
The purpose of Workers’ Compensation is to provide injured workers and those who depend
upon them with a means of support when they are unable to work because of a work-related
disability. Its purpose also is to bring about a prompt recovery.
2. What is a "Work-Related Injury or Illness"?
The term "Work-Related Injury or Illness" is used to describe any injury or disease which
results from work or working conditions and which occurs during the employee's service to the
employer.
3. Who administers a Workers’ Compensation claim?
PMA Management Corp. of New England is the claims administrator for The City of
Waterbury and Waterbury Board of Education. They administer all compensation benefits an
injured worker is entitled to receive. If you have any questions about Workers’ Compensation,
contact the City’s Risk Management Department at 203-574-6840 or PMA Management Corp.
of New England at 203-679-3900 or 1-800-379-0276.
4. How do you qualify for benefits?
Report the injury or illness to your supervisor immediately. The employee must specify what,
where, when and how it happened and provide enough information so that your supervisor can
complete the First Report of Injury form.
Prompt reporting is key. Benefits are automatic for accepted work-related injuries or illnesses.
5. What if you need prescription drugs?
Employees requiring prescriptions must have them filled at a pharmacy that participates with
PMA’s Pharmacy Benefit Manager, Express Scripts. Most pharmacies will participate in this
network but please contact Express Scripts at 1-888-786-9640 to confirm.
6. What if you are currently being treated for a workers’ compensation injury or illness?
The City of Waterbury and Waterbury Board of Education Workers’ Compensation medical
care plan is for injuries occurring on or after the plan’s effective date. If you have an
established and approved Workers’ Compensation claim and are currently being treated for that
injury, there are no changes. You can continue your treatment with your established treating
provider.
City of Waterbury and Waterbury Board of Education
4
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
7. Where do you obtain medical treatment?
Prompt medical care is a key element to a fast recovery from an injury or illness. Emergency
medical care and medical follow-up treatment can often mean the difference between complete
recovery from an injury or lasting physical disability.
If you become injured at work, you should report your injury to your department supervisor
and proceed to one of the plan’s Occupational Health / Walk In Medical Centers listed
(St Mary’s Hospital or Concentra). If you become injured when the centers are closed, you
should go to the nearest emergency department.
8. What if you need continuing medical treatment?
In the event an employee's injury or illness requires additional medical care beyond the initial
visit to a primary care center or the emergency department, a primary treating physician within
the MCMC CareSys network should be requested. This physician will continue to provide
necessary treatment and referrals to other specialists if or when needed.
Employees are required to obtain treatment from providers in the approved plan.
Failure to do so may suspend an employee’s right to receive Workers’ Compensation
benefits, subject to the order of a Workers’ Compensation Commissioner.
Should your injury require specialty treatment not available in The MCMC CareSys Medical
Care Plan, a consultant from an approved list established by the Workers’ Compensation
Commission may be chosen for your treatment. Please see The City of Waterbury’s Risk
Manager for guidance.
9. What do you do if the doctor releases you to modified/light duty work?
Bring your physician's completed copy of the “Work Status Report” to your department
supervisor or HR representative immediately. The City of Waterbury and Waterbury Board
of Education will try to provide you with a temporary, modified duty position to meet your
doctor's specified restrictions. If you have any questions regarding the
Modified / Light Duty process, please contact your department supervisor or
HR representative.
Once your Medical Provider releases you to return to full duty, the temporary, disability
wage support stops.
10. What if you have further questions?
If you have further questions regarding your Workers’ Compensation benefits, contact The
City’s Risk Management Department at 203-574-6840 or PMA Management Corp. of New
England Claims Manager at 1-203-679-3900 or 1-888-476-2669.
11. What if you have questions about your medical treatment?
MCMC CareSys can review the medical care and services being provided to you. They can be
contacted at 1-888-476-2669.
City of Waterbury and Waterbury Board of Education
6
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
CITYOFWATERBURYandWATERBURYBOARDOFEDUCATION
Workers'CompensationMedicalCarePlanProviderSpecialtyIndex
EffectiveDate‐September15,2016
ApprovedSpecialties
RepresentsthecorespecialtiescoveredwithintheCityofWaterburyand
WaterburyBoardofEducation'scustomizedMedicalCarePlan
Allergy/Immunology

OccupationalMedicine
Audiology

OccupationalTherapy
CardioVascularSurgery

Oncology
Cardiology

Ophthalmology
Cardiothoracic

Optometry
ChiropracticMedicine

OralandMaxillofacial
Dentistry

OrthopedicSurgery
Dermatology

Osteopathy
Endocrinology

Otolaryngology
Family/GeneralPractice

PainManagement
Gastroenterology

PhysicalMedicine&Rehabilitation
GeneralHospitalServices

PhysicalTherapy

GeneralSurgery

PlasticSurgery

HandSurgery

Podiatry
HandTherapy Psychiatry
Head&NeckSurgery Psychology
Hematology PulmonaryMedicine
InfectiousDiseases Radiology

InitialCare Rheumatology
InternalMedicine SocialWork
Nephrology SurgicalCenters

NeurologicalSurgery ThoracicSurgery

Neurology Urology
OBGYN VascularSurgery
ShouldaninjuryrequirespecialtytreatmentnotcoveredintheWaterburyMedicalCarePlan,aproviderfrom
theapprovedproviderlistestablishedbytheWorker'sCompensationCommissionmaybechosenfortreatment.
PleasecontactPMAortheCityofWaterbury'sRiskManagementTeamforguidance.
City of Waterbury and Waterbury Board of Education
7
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
City of Waterbury and Waterbury Board of Education
Medical Network for Workers’ Compensation
Emergency care may be obtained at the nearest emergency department or center. For your convenience the closest emergency
department to your primary place of employment is:
Emergency Care
Saint Mary's Hospital
56 Franklin Street
Waterbury, CT 06706
(203) 709-6000
Waterbury Hospital
64 Robbins Street
Waterbury, CT 06721
(203) 573-6000
Occupational Health / Walk In Medical Centers
Concentra Medical Center - Waterbury
8 South Commons Road
Waterbury, CT 06704
(203) 759-1229
Saint Mary's Occupational Health and
Diagnostic Center
1312 West Main Street
Waterbury, CT 06708
(203) 709-3740
Saint Mary's Hospital Urgent Care
Center
Waterbury Urgent Care
1312 West Main Street
Waterbury, CT 06708
(203) 709-4575
General Surgery
Abdel Richi, M.D., LLC
1389 West Main Street
Suite 322
Waterbury, CT 06708
(203) 753-0877
Richi, Abdel MD
Alliance Medical Group Surgery
1625 Straits Turnpike, Suite 200
Middlebury, CT 06762
(203) 568-2929
Knight, David MD
Shetty, Jayakara MD
Middlebury Surgical, LLC
687 Straits Turnpike
Suite 2A
Middlebury, CT 06762
(203) 598-0235
Tripodi, Guiseppe MD
Hand Surgery
Active Orthopaedics, PC
Turnpike Office Park
1579 Straits Turnpike
Middlebury, CT 06762
(203) 758-1272
Carlson, Erik J. MD
Neurosurgery, Orthopaedic & Spine Specialists, PC
(NOSS)
1320 West Main Street
Waterbury, CT 06708
(203) 755-7115
Manzo, Richard MD
Nelson, Andrew MD
Orthopedic Associates of Hartford PC
499 Farmington Avenue, Suite 300
Farmington, CT 06032
(860) 549-3210
Bontempo, Nicholas MD
Burton, Kevin MD
Caputo, Andrew MD
Linburg, Richard MD
Stanley J. Foster III, M.D., P.C.
1625 Straits Turnpike, Suite 108
Middlebury, CT 06762
(203) 757-0583
Foster III, Stanley J . MD
City of Waterbury and Waterbury Board of Education
8
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
Neurology
Alliance Medical Group
1625 Straits Turnpike Suite 302
Middlebury, CT 06762
(203) 573-9512
Zhang, Jianhui (Jane) MD
Associated Neurologists, PC
1389 West Main Street
Tower 1, Suite 212
Waterbury, CT 06706
(203) 748-2551
Culligan, Neil MD
Grecco, David MD
Markind, Samuel MD
Wirz, Diane MD
Neurological Specialists, P.C.
4 Corporate Drive, Suite 192
Shelton, CT 06484
(203) 924-8664
Barasch, Philip M., MD
Beck, Lawrence, MD
Butler, James B., MD
Webb, Lisa B., MD
Neurosurgery
Hartford HealthCare Medical Group
1781 Highland Avenue
Suite 106
Cheshire, CT 06410
(203) 271-2120
Bauman, Joel MD
HHC PhysiciansCare, Inc.
85 Barnes Road
Wallingford, CT 06492
(203) 265-9122
Bauman, Joel MD
Neurosurgery, Orthopaedic & Spine
Specialists, PC (NOSS)
500 Chase Parkway
Waterbury, CT 06708
(203) 755-6677
Forshaw, David MD
Karnasiewicz, Michael MD
Mushaweh, Jarob MD
Strugar, John MD
Waitze, Alan MD
Neurosurgery, Orthopaedic & Spine
Specialists, PC (NOSS)
330 Bridgeport Avenue
Shelton, CT 06484
(203) 755-6677
Gorelick, Judith MD
Orthopedic Associates of Hartford
220 Farmington Avenue
Farmington, CT 06032
(860) 522-7121
Lange, Stephan MD
Ophthalmology
Eye Center - A Medical & Surgical Group, PC
415 Highland Avenue
Cheshire, CT 06410
(203) 272-5494
Fezza, Andrew MD
Marks, Peter MD
Martone, James MD
Masi, Paul MD
Milner, Mark MD
Eye Center - A Medical & Surgical Group, PC
2880 Old Dixwell Avenue
Hamden, CT 06518
(203) 248-6365
Fezza, Andrew MD
Marks, Peter MD
Martone, James MD
Masi, Paul MD
Milner, Mark MD
Swan, Andrew MD
OptiCare Eye Health Centers, Inc.
811 East Main Street
Torrington, CT 06790
(860) 496-8668
Dua, Neeru MD
OptiCare Eye Health Centers, Inc.
87 Grandview Avenue
Waterbury, CT 06708
(203) 574-2020
Capuano, Mara OD
Cervantes, Lorenzo MD
Dua, Neeru MD
Fei, Eugene OD
Gershon, Meredith MD
Gilbert, Richard MD
Konykhov, Olga MD
Nguyen, Kelly OD
Oberman, Jeffrey MD
Peterson, W. Scott MD
So, Kevin OD
Yimoyines, Dean MD
City of Waterbury and Waterbury Board of Education
9
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
Orthopedics
Active Orthopaedics, PC
Turnpike Office Park
1579 Straits Turnpike
Middlebury, CT 06762
(203) 758-1272
Carlson, Erik J. MD
Kaplan, Michael MD
CT Spine and Disc Institute
1579 Straits Turnpike
Middlebury, CT 06762
(203) 758-2003
Raftery, Charles MD
Neurosurgery, Orthopaedic & Spine
Specialists PC (NOSS)
2 Pomperaug Office Park, Suite 308
Southbury, CT 06488
(203) 264-2878
Flynn, Jr., William MD
Taylor, Glenn MD
Watson, Frederick MD
Neurosurgery, Orthopaedic & Spine
Specialists PC (NOSS)
500 Chase Parkway
Waterbury, CT 06708
(203) 755-6677
Flynn, Jr., William MD
Taylor, Glenn MD
Watson, Frederick MD
Neurosurgery, Orthopaedic & Spine
Specialists PC (NOSS)
1320 West Main Street
Waterbury, CT 06708
(203) 755-7115
Manzo, Richard MD
Nelson, Andrew MD
Orthopedic Associates of Hartford
499 Farmington Avenue, Suite 300
Farmington, CT 06032
(860) 549-3210
Aronow, Michael MD
Barnett, Peter MD
Becker, Gerald MD
Benthien, Ross MD
Bontempo, Nicholas MD
Burns, Jeffrey MD
Burton, Kevin MD
Caputo, Andrew MD
Carangelo, Robert MD
Davis, Stephen L. MD
Dugdale, Thomas MD
Orthopedic Associates of Hartford
(cont.)
Esmende, Sean MD
Froeb, Richard MD
Fulkerson, John MD
Grady-Benson, John MD
Kime, Charles MD
Krompinger, W. Jay MD
Lena, Christopher MD
Lewis, Courtland MD
Linburg, Richard MD
Miranda, Michael MD
Nagarkatti, Durgesh MD
Rios, Clifford MD
Schutzer, Steven MD
Shekhman, Mark MD
Sullivan, Raymond MD
Zimmermann, Gordon MD
Waterbury Orthopaedic Associates
1211 West Main Street
Waterbury, CT 06708
(203) 755-0163
Mariani, Michelle MD
Olson, Eric MD
Rodin, Dennis MD
Pain Management
Active Orthopaedics, PC
1579 Straits Turnpike
Middlebury, CT 06762
(203) 758-1272
Glassman, David B, MD
Neurosurgery, Orthopaedic & Spine Specialists, PC (NOSS)
500 Chase Parkway
Waterbury, CT 06708
(203) 755-6677
Ghaly, Tamer MD
Johar, Sandeep DO
Neurosurgery, Orthopaedic & Spine Specialists, PC (NOSS)
166 Waterbury Road
Suite 300
Prospect, CT 06712
(203) 755-6677
Johar, Sandeep DO
Orthopedic Associates of Hartford
499 Farmington Avenue
Suite 300
Farmington, CT 06032
(860) 549-3210
Memmo, Pietro MD
Codispoti, Vincent MD
RehabHealth, PC
1320 West Main Street, Suite #2
Waterbury, CT 06708
(203) 755-9355
Lichter, Arlen MD
Nisenbaum, Michelle MD
City of Waterbury and Waterbury Board of Education
10
Effective Date: 9/15/2016
Revised Date: 1/1/2019
Revised Date: 4/1/2019
Physical Medicine & Rehabilitation
Neurosurgery, Orthopaedic & Spine
Specialists, PC (NOSS)
500 Chase Parkway
Waterbury, CT 06708
(203) 755-6677
Darling, Alisa MD
Orthopedic Associates of Hartford
499 Farmington Avenue
Suite 300
Farmington, CT 06032
(860) 549-3210
Codispoti, Vincent MD
Memmo, Pietro MD
RehabHealth, PC
1320 West Main Street, Suite #2
Waterbury, CT 06708
(203) 755-9355
Lichter, Arlen MD
Nisenbaum, Michelle MD
Physical Therapy Services
Access Rehab Centers
1625 Straits Turnpike
Middlebury, CT 06762
(203) 598-0400
Access Rehab Centers
305 Church Street, Suite 16
Naugatuck, CT 06770
(203) 723-4010
Access Rehab Centers
84 Oxford Road - Route 67
Oxford, CT 06478
(203) 881-0830
Access Rehab Centers
Bennett Square #70-G
134 Main Street South
Southbury, CT 06488
(203) 267-4060
Access Rehab Centers
131 Main Street
Thomaston, CT 06787
(860) 283-4700
Access Rehab Centers **
715 Lakewood Road
Waterbury, CT 06704
(203) 759-1122
Access Rehab Centers
2154 East Main Street
Waterbury, CT 06705
(203) 575-0516
Access Rehab Centers
134 Grandview Avenue
Waterbury, CT 06708
(203) 573-7130
Access Rehab Centers
22 Tompkins Street
Waterbury, CT 06708
(203) 419-0381
Access Rehab Centers
64 Robbins Street
Waterbury Hospital
Waterbury, CT 06708
(203) 573-6041
Access Rehab Centers
650 Wolcott Road
Wolcott, CT 06716
(203) 879-6700
Physical Therapy & Sports Medicine
Center
1183 New Haven Road, Suite 104
Naugatuck, CT 06770
(203) 723-0722
Physical Therapy & Sports Medicine
Center **
18 South Center Street
Southington, CT 06489
(860) 621-5054
Physical Therapy & Sports Medicine
Center
1211 West Main Street
Waterbury, CT 06708
(203) 753-6043
Physical Therapy & Sports Medicine
Center
27 Depot Street
Watertown, CT 06795
(860) 274-1487
Select Physical Therapy **
117 Sharon Road
Mall View Plaza
Waterbury, CT 06705
(203) 756-2334
Select Physical Therapy
76 Westbury Parkway Suite 201E
Watertown, CT 06795
(860) 274-7573
Select Physical Therapy
1320 West Main St., Bldg 2 Unit #5
Waterbury, CT 06708
(203) 573-9518
Saint Mary’s Hospital Physical
Therapy
799 New Haven Road
Naugatuck, CT 06770
(203) 720-1750
Saint Mary’s Hospital Physical
Therapy
1981 East Main Street, Suite 2
Waterbury, CT 06705
(203) 709-6232
** Aqua Therapy Available
Should your injury require specialty treatment not available in The MCMC CareSys Medical Care Plan, a consultant from an approved list established
by the Workers’ Compensation Commission may be chosen for your treatment. Please see The City of Waterbury’s Risk Manager for guidance.
The City will comply with the Commissioner’s decision regarding second opinion requests.
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Completed 21 March 2021

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