For Members of the ACCG Insurance Programs

Get Started NOW to meet the Application Deadline

September 15, 2016

PLEASE READ This step-by-step workbook will assist you in qualifying for the safety discount.

The Safety Discount Program is an ongoing, year-round

process.

To be eligible for the ACCG Safety Discount during the 2017 policy year, please complete the requirements outlined in this booklet between

January 1, 2016 and December 31, 2016.

*NEW* ACCG - GSIWCF SAFETY ACTION PLAN *NEW* The SAFETY ACTION PLAN is a new requirement for the ACCG – GSIWCF members this year. The Member Organization's leadership and safety team is required to review their workers’ compensation loss trends over the last five years. The next step is to develop goals that will address risk causing the most claim activity.

ACCG and LGRMS will conduct several webinars in March 2016 to outline this requirement and answer questions. See page 12 for more information.

The SAFETY DISCOUNT VERIFICATION FORM can be sent anytime during the year.

Please copy the applicable SAFETY DISCOUNT VERIFICATION FORMS included in this booklet. The FORMS will NOT be sent in a separate mailing.

SUBMIT THE ACCG SAFETY DISCOUNT VERIFICATION FORMS

ANYTIME During the Year, BUT NO LATER THAN September 15, 2016

Please contact Penny Henderson if you have any questions. 404-589-7834 or phenderson@accg.org

191 Peachtree Street NE Suite 700 Atlanta, Georgia 30303 p 800.858.2224 fx 404.522.1897 accg.org

DATE: January 2016 TO: ACCG - IRMA Insurance Contacts & Safety Coordinators ACCG - GSIWCF Insurance Contacts & Safety Coordinators COPY: ACCG - IRMA & ACCG - GSIWCF County Chairmen & Managers ACCG - GSIWCF Executive Directors FROM: Penny J. Henderson ACCG Insurance Programs SUBJ: ACCG Safety Incentive Discount Program ACCG - Interlocal Risk Management Agency 2017 - 2018 Policy Period ACCG - Group Self-Insurance Workers' Compensation Fund 2017 Policy Period ACCG Insurance Programs encourages workplace safety as a win-win for the member and its employees. When safety is practiced in the day-to-day operations, everyone benefits by minimizing the number and severity of losses impacting the lives of your coworkers and citizens. Saving a life is the greatest advantage of the Safety Discount Program! ACCG Insurance Programs promotes a safer environment by offering a significant premium discount for those members who elect to participate in the Safety Discount Program. Not only can this program save the lives of citizens or employees, it can reduce the member's premium by controlling the losses and payouts to claims, thereby decreasing future insurance costs. The ACCG - Interlocal Risk Management Agency Board of Trustees has approved a 5% safety discount, to a maximum of $5,000 on the property and liability premium. Last year, 98 of our 109 eligible members met the qualifications to receive the discount, resulting in premium savings of over $465,000 during the 2015 - 2016 policy year. This program is designed for counties to avoid or minimize the severity of their property and liability losses with an emphasis on law enforcement; therefore, the discount is not applicable to authorities.

ACCG Safety Discount Program January 2016

The ACCG - Group Self-Insurance Workers’ Compensation Fund Board of Trustees has approved a 7.5% discount on the 2017 workers’ compensation premium. In 2016, 81% (135) of the 166 ACCG - GSIWCF members qualified for the discount, collectively saving over $2.7 million dollars on their 2016 premium. The discount is available for both counties and authorities. Members of ACCG – GSIWCF and ACCG – IRMA must meet all of the requirements to be considered for the safety discount. To qualify for the Safety Discount, a member must agree to implement and maintain a basic safety program and appoint a Safety Coordinator. For your organization to receive a Safety Discount, please review the specific standards outlined in the 2017 ACCG Safety Discount Program booklet. Detailed instructions on 'HOW TO COMPLY' are outlined on page 5 in the workbook.

THE SAFETY DISCOUNT PROGRAM IS AN ONGOING, YEAR-ROUND PROCESS.

o Part of the application process is for the members of each Insurance Program to complete the SAFETY DISCOUNT VERIFICATION FORM.

o A SAFETY DISCOUNT VERIFICATION FORM is to be signed by the County

Chairman or the Executive Director (if your organization is not a county).

o The form from each Insurance Program will only need to be submitted once. It is not necessary to send the original. If confirmation upon receipt is necessary, then please send via fax or email and retain your evidence of transmittal.

o SEND ANYTIME during the year, but no later than September 15, 2016.

o Once the requirements are met and the form(s) is submitted, the

application process is finished. After ACCG receives the forms from the members, a copy is forwarded to LGRMS.

o If the safety discount application is NOT submitted, then your organization

will NOT be eligible for the discount.

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ACCG Safety Discount Program January 2016

Our members have access to an exceptional resource of safety and loss control expertise through Local Government Risk Management Services. LGRMS is a non-profit organization sponsored by the Insurance Programs of the Association County Commissioners of Georgia and Georgia Municipal Association. All of LGRMS’ services are provided at no additional charge to ACCG - IRMA and ACCG - GSIWCF members. Each member of the ACCG Insurance Funds is assigned a LGRMS field representative to provide expertise in loss control and safety. Steve Shields, Chris Ryan, John McIntyre and Natalie Sellers are the LGRMS loss control representatives. They are available to share their knowledge with our members in implementing and maintaining a successful safety program. LGRMS will perform an annual audit to confirm the safety criteria and training requirements have been met. Please see page 21 since the Field Representatives' districts have been changed. If you have any questions about the ACCG Safety Discount Program, please call me at 404-589-7834 or 800-858-2224. You may direct your training inquiries to Shamilla Jordan at LGRMS 678-686-6282. LGRMS can also be reached at 678-686-6279 or 800-650-3120 for technical assistance or contact your LGRMS field representative noted on page 20. cc: David Uhlman, Property & Casualty Insurance Program Director Dan Beck, Director of Local Government Risk Management Services

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ACCG Safety Discount Program

ELIGIBILITY REQUIREMENTS

INTERLOCAL RISK MANAGEMENT AGENCY [Property & Liability]

and

GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND Members of the ACCG Insurance Programs who comply with the following safety incentive discount requirements will be eligible to receive a discount on their annual insurance premiums. ACCG – IRMA 5% discount July 1, 2017-18 Policy Year

[Counties only] [maximum of $5,000] ACCG – GSIWCF 7.5% discount January 1, 2017 Policy Year The required procedures are the foundation for an effective safety program, and are used as a basic guideline for implementing a loss control and safety program. ACCG Insurance Programs encourages its members to provide a safer workplace by adding additional procedures based on the needs of the organization.

The ACCG SAFETY DISCOUNT VERIFICATION FORM must be completed and submitted to ACCG Insurance Programs by September 15, 2016. Local Government Risk Management Services will be notified and will make an appointment to conduct the safety audit. Once the confirmation is received from LGRMS indicating the member has passed their audit, the discount will be applied to your annual insurance premium.

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HOW TO COMPLY with the following standards to receive the safety discount. THE REQUIREMENTS BELOW APPLY TO MEMBERS OF BOTH INSURANCE PROGRAMS.

1. A SAFETY COORDINATOR MUST BE APPOINTED. The Safety Coordinator may be any person who works in the organization. A new position does not need to be created in order to comply with these standards. One individual may serve as the ACCG - IRMA and ACCG – GSIWCF Safety Coordinator. The Safety Coordinator is responsible for working with management to coordinate the actions below.

SAFETY COORDINATOR RESOLUTION [Appendix A]

o ATTEND SAFETY COORDINATOR MODULES I, II, OR III training presented by

Local Government Risk Management Services (LGRMS). A Safety Coordinator is required to take one Safety Coordinator class per year until they have completed the all of the modules. Once all three sessions have been attended by the Safety Coordinator, the SAFETY COORDINATOR TRAINING MODULES will not need to be repeated, as long as the Safety Coordinator does not change. In the event a new Safety Coordinator is appointed by the member, the new Coordinator will need to complete the training.

o COORDINATE QUARTERLY SAFETY MEETINGS. A minimum of four safety review meetings must be held each year. If all four of the meetings have not taken place by the time the SAFETY DISCOUNT VERIFICATION FORM is due, they must be scheduled to take place in quarterly increments throughout the policy year. A record of the meeting, including topics discussed and a sign-in sheet to verify those in attendance should be maintained to document compliance with this requirement. LGRMS will provide assistance in implementing and holding safety meetings, if requested.

o COORDINATE SAFETY TRAINING AND IMPLEMENT SAFETY RULES for

supervisors and employees. They will ensure that appropriate documentation is posted at or near job-sites that instruct injured employees how they should proceed in the event of an on-the-job accident.

o COORDINATE SAFETY INSPECTIONS to help identify potential claim exposures.

Items to be documented for periodic inspections are all county vehicles, buildings & grounds, equipment & machinery, and work practices & procedures. LGRMS can provide county members with checklists and other assistance to help comply with this requirement.

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o REVIEW ALL INCIDENTS AND ACCIDENTS [INJURY OR PROPERTY DAMAGE]

involving employees and the general public to determine the cause, make recommendations for improvements to prevent or minimize future occurrences. Document and maintain records and implement follow-up actions.

The following is a suggested timetable for the Safety Coordinator: January, February and March.

o Schedule a safety meeting for the first quarter.

o Register an employee to attend a LGRMS workshop to satisfy the training requirement.

o Register to attend the LGRMS Safety Coordinator Modules I, II, and III, until all are completed.

o Conduct safety inspections.

April, May and June.

o Present another quarterly safety meeting.

o Ensure an employee will participate in a LGRMS workshop.

o Attend a LGRMS safety coordinator training course, if necessary.

o Comply with the other pertinent standards listed in the workbook.

July, August and September.

o The third quarterly safety meeting is to be held.

o Confirm an employee has attended the LGRMS workshop to satisfy both the IRMA and GSIWCF training requirement.

o Review all incidents and accidents.

o Coordinate safety inspections with LGRMS Field Representative.

October, November and December.

o Complete the final quarterly safety meeting.

o Attendance is mandatory at the LGRMS workshop (if haven’t done so already).

o Meet all of the remaining eligibility requirements.

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2. An EMPLOYEE from your organization must attend a minimum of

ONE TRAINING SESSION administered by Local Government Risk Management Services, in addition to the Safety Coordinator attending the Safety Coordinator Modules previously described. The training can be on any topic LGRMS presents other than Health & Wellness workshops.

ALL TRAINING IS TO BE COMPLETED IN THE 2016 CALENDAR YEAR. However, you are encouraged to take advantage of the LGRMS training

opportunities prior to the fourth quarter due to course availability. On-site courses DO count towards the training requirement. On-line courses and Health & Wellness Workshops do NOT apply toward the Safety Discount. A schedule of training programs administered by LGRMS may be viewed on their website www.lgrms.com or obtained by calling 800-650-3120.

The single factor that most often prevents our members from receiving the Safety Discount is NOT completing the training requirement.

3. Members agree to cooperate and support the efforts of the

LOCAL GOVERNMENT RISK MANAGEMENT SERVICES’ safety and loss control programs. Members will be required to respond to LGRMS’ recommendations in writing within ninety (90) days following a loss control visit. Although the member does not have to conform to the recommendations explicitly, they must take the initiative in developing a plan to maximize LGRMS’ expertise, or provide an explanation as to why this opportunity for improvement was not taken.

4. The member shall implement and oversee a DRUG-FREE WORKPLACE PROGRAM

to include, at a minimum, the following: o A DRUG-FREE WORKPLACE NOTICE on all employment applications and/or in the

personnel policy. o A written DRUG-FREE WORKPLACE POLICY regarding drug or alcohol use in the

workplace. MODEL SUBSTANCE ABUSE POLICY [Appendix B] Exhibit A Observation Checklist Exhibit B Pre-Employment Consent & Release Form Exhibit C Safety Sensitive Positions

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5. A SEAT BELT POLICY must be implemented and enforced by the member. The

purpose of this policy is to establish mandatory seat belt use as an organizational priority and designate responsibility for implementation and enforcement. It is essential that DRIVERS and PASSENGERS use their seat belts while traveling on official company business. The SEAT BELT POLICY applies to all employees and occupants of any vehicle driven by employees, including rentals and personal vehicles when used on official company business. The driver of the vehicle is responsible for enforcing seat belt use by all occupants. When possible, it is also employees’ duty to use their seat belts while operating equipment. The member shall emphasize to the new employee the county/authority recognizes that seat belts are extremely effective in preventing injuries and loss of life in a crash. This commitment will be demonstrated by requiring a SEAT BELT POLICY by the county, and taking reasonable steps to enforce compliance with the policy. Managers and supervisors have an obligation to strongly encourage seat belt usage by communicating the benefits to their employees, monitoring compliance, evaluating effectiveness and taking disciplinary action against violations. SEAT BELT POLICY [SAMPLE 1 & 2] [Appendix C]

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ACCG

INTERLOCAL RISK MANAGEMENT AGENCY [Property & Liability]

The following requirements apply only to COUNTY MEMBERS of the ACCG Interlocal Risk Management Program (ACCG – IRMA).

AUTHORITIES are ineligible for this safety discount.

1. POLICY MANUALS must be in place as follows:

o A PERSONNEL POLICY MANUAL must be in place for all COUNTY DEPARTMENTS. This can be one policy manual or multiple policy manuals covering all county departments. All personnel policies must have a documented annual review and update. These policies should be included:

• Hiring / Termination • Employee / Supervisor Training • Harassment • EEOC & Non-Discrimination • Email / Internet Policy • Drug Free Workplace • Motor Vehicle

o SHERIFF OFFICES must have a written POLICY MANUAL in place. The manual must

have a documented annual review and update. The manual should be based on “Georgia Sheriffs’ Association Georgia Standards”. These policies should be included:

If different from County -

• Hiring / Termination • Employee / Supervisor Training • Harassment • EEOC & Non-Discrimination

Plus - • Motor Vehicle Operations • Pursuit • Use of Force • Arrests • Internal Affairs

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o SHERIFF DEPARTMENTS WITH JAIL FACILITIES must have a written POLICY MANUAL

in place. The manual must have a documented annual review and update. The manual should be based on “Georgia Sheriffs’ Association Georgia Standards for Adult Pretrial Detention Facilities”.

2. COUNTY JAIL FACILITIES which are operated by the SHERIFF’S DEPARTMENT

should be staffed to permit jailers and dispatchers to perform separate job duties. A Georgia Sheriffs’ Association Staffing Analysis & Report is recommended to help determine proper staffing levels for the jail operations. These policies should be included:

• Inmate Medical • Jail Suicide Prevention • Civil Rights

3. MOTOR VEHICLE REPORTS (MVR) must be obtained on all new employees

before they are allowed to drive county vehicles. Automobiles are a major source of liability losses for county government. The purpose of this requirement is to assist in determining the risks of drivers that are behind the wheel of county vehicles.

ACCG anticipates that this will be the first step in effectively controlling losses by setting policies in place to restrict the driving of employees with poor driving records, although this not a requirement to receive the safety discount. ACCG will continue to allow the counties to make their own decisions as to who will drive county vehicles during the course of employment.

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ACCG

GROUP SELF-INSURANCE WORKERS' COMPENSATION FUND

The following requirements apply to ALL members of the ACCG Group Self-Insurance Workers' Compensation Fund (ACCG – GSIWCF).

1. The following PERSONNEL AND ADMINISTRATIVE PROCEDURES are to be

included during the EMPLOYEE ORIENTATION for each new employee: o The PANEL OF PHYSICIANS and the BILL OF RIGHTS FOR THE INJURED WORKER

must be explained to each new employee by the member. A signature is required from each new employee indicating this has been accomplished.

o A valid PANEL OF PHYSICIANS must be posted and maintained in prominent places at each work site as required by Georgia law.

PANEL OF PHYSICIANS [Appendix D]

o A valid A BILL OF RIGHTS FOR THE INJURED WORKER must be posted and

maintained in prominent places at each work site as required by Georgia law.

A BILL OF RIGHTS FOR THE INJURED WORKER [Appendix E]

o Explain the policies that are relevant to the employee’s position. (e.g. SEAT BELT POLICY, RETURN TO WORK POLICY, etc.)

2. The member must have a RETURN TO WORK POLICY in place to encourage

various departments to accommodate the use of transitional employment, if an injured employee is unable to perform normal job duties during their recovery period. The member must make a reasonable good-faith effort to return an injured worker to work at a modified job, if approved by the doctor. The ACCG Claim Administration Services will notify the member when an employee has been released to modified duty, but it will be the member’s responsibility to make a reasonable search to determine if a position is available. RETURN TO WORK PROGRAM [Appendix F]

RETURN TO WORK POLICY [Appendix G]

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3. SAFETY ACTION PLAN

THIS IS A NEW REQUIREMENT FOR THE ACCG – GSIWCF MEMBERS THIS YEAR. It is important for the leadership and safety team to understand what’s causing or contributing to their workers’ compensation losses. The analysis provides valuable information on where to focus loss control efforts in the future to prevent or mitigate losses. In March, ACCG will provide the member's loss history to each Safety Coordinator for the analysis. The safety coordinator, county leadership and/or safety team are to agree on risk reduction goals for the remainder of the year, and complete a Safety Action Plan. The Safety Action Plan template is provided in the booklet. The Loss Control Field Representative is available to assist as needed.

SAFETY ACTION PLAN [Appendix H]

PLEASE NOTE: MARCH 2016 After the analysis is received from ACCG in March and the safety coordinator, leadership and/or safety team have reviewed applicable loss trends over the last five years, the auditors will want to view the developed goals which address the risks causing the most claim activity.

A SAFETY ACTION PLAN is provided in the booklet.

ACCG and LGRMS will conduct several webinars in March 2016 to outline this requirement and any answer questions.

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163 Members / January 2016Property & Liability

INTERLOCAL RISK MANAGEMENT AGENCY

Appling County10/09/1987

Atkinson County10/01/2010

Atkinson County Solid WasteAuthority

07/01/2010

Bacon County01/01/2006

Baker County05/01/2000

Baldwin County03/01/2003

Banks County10/01/1987

Bartow County01/01/2003

Bartow-Cartersville JointDevelopment Authority

05/01/2005

Bartram Trail Regional LibrarySystem

02/01/2003

Bleckley County01/21/2003

Brantley CountyBryan County11/01/1988

Bulloch County04/15/2004

Butts County12/01/1998

Butts County Water & SewerAuthority

02/01/1998

Carroll County Water Authority01/01/2003

Charlton County06/01/1991

Chattooga County03/05/2003

Clay County10/01/1987

Clinch County10/01/1987

Clinch County DevelopmentAuthority

02/01/2011

Coastal Plain Regional Library08/01/2006

Coffee County01/01/2005

Colquitt County07/01/1991

Columbia County10/01/1994

Conyers-Rockdale Library System07/24/2003

Cook County06/07/1997

Crawford County12/12/2000

Crisp County09/01/2001

Cusseta-Chattahoochee UnifiedGovernment

03/05/1998

Dade County03/01/1995

Dawson County03/01/1998

DeKalb Private Hospital Authority07/12/2012

Decatur County01/24/2005

Development Authority of BartowCounty

10/01/2004

Development Authority of DeKalbCounty

03/14/2012

Development Authority ofJefferson County

10/01/2002

Development Authority of MonroeCounty

01/22/2001

Development Authority of RabunCounty

07/20/2012

Dodge County05/25/1999

Douglasville - Douglas CountyWater & Sewer Authority

09/01/2003

Early County10/01/2002

Early County Department of PublicSafety

10/01/2004

Eatonton-Putnam Water & SewerAuthority

12/01/2007

Echols County ConsolidatedGovernment

02/03/1995

Effingham County10/01/1987

Ellijay-Gilmer County Water &Sewer Authority

07/01/2010

Emanuel County10/01/2000

Emanuel County DevelopmentAuthority

10/01/2002

Evans County01/01/1999

Fannin County12/01/1995

Fannin County Water Authority01/01/2015

Flint River Regional Library01/14/2003

Floyd County04/01/2005

Forsyth County12/31/2001

Franklin County11/24/1993

Franklin County Industrial BuildingAuthority

08/22/2012

Gilmer County02/15/2005

Glascock County08/01/2015

Glynn County04/25/2009

Gordon County10/01/1991

Grady County12/31/1987

Greene County01/01/1996

Greene County RecreationComplex

10/01/2007

Hancock County04/01/2007

Haralson County03/05/2014

Harris County10/01/2002

Hart County01/01/2003

Hart County Water & SewerAuthority

04/01/2007

Heard County10/01/2002

Henry County02/19/1992

Henry County Library System06/01/2002

Houston County07/01/2000

Houston County DevelopmentAuthority

04/01/2011

Jackson County07/10/1988

Jasper County10/04/1988

Jasper County Water & SewerAuthority

03/15/2001

Jeff Davis County03/02/2005

Jefferson County07/01/1993

Jefferson County Library System01/01/2003

Jenkins County05/15/2015

Johnson County10/26/1992

Jones County04/19/2005

Lamar County02/20/1988

Laurens County12/31/2000

Lee County01/13/2003

Lee County Utilities Authority07/15/2003

Long County04/01/1994

Lower Chattahoochee RegionalTransit Authority

08/17/2012

Lowndes County07/01/1994

Lumpkin County09/19/1997

Lumpkin County Water &Sewerage Authority

01/01/2001

McDuffie County01/15/2001

McIntosh County05/30/2002

McIntosh County IndustrialDevelopment Authority

07/01/2002

Meriwether County04/01/2006

Meriwether County Water &Sewerage Authority

08/04/2010

Middle Flint Regional 911Authority

08/31/2004

Miller County03/26/1995

Mitchell County01/17/1992

Monroe County02/01/1999

Montgomery County09/08/2002

Morgan County04/03/1991

Oconee County10/01/1987

Oconee County IndustrialDevelopment Authority

07/15/1997

Oglethorpe County04/15/1988

Paulding County07/01/1994

Paulding County Airport Authority11/12/2008

Paulding County IndustrialBuilding Authority

04/01/2007

Pierce County05/04/2004

Pike County12/31/1997

Pike County Parks and12/01/2009

Recreation AuthorityPolk County03/01/1996

Polk County Water, Sewage &Solid Waste Authority

06/12/2012

Pulaski County01/15/2004

Putnam County10/18/2003

Rabun County04/06/1992

Randolph County01/24/2015

Rockdale County07/01/1991

Satilla Regional Water & SewerAuthority

01/01/2002

Schley County12/31/2002

Screven County10/01/1987

Seminole County06/15/2008

Sinclair Water Authority07/01/2003

South Georgia Regional LibrarySystem

04/01/1997

Southwest Georgia RegionalCommission

07/01/2004

Stephens County12/31/1999

Stephens County DevelopmentAuthority

10/06/2005

Stewart County07/17/1988

Stewart County Water & SewerAuthority

07/17/1988

Sumter County01/01/2004

Talbot County05/01/2011

Taliaferro County04/26/2003

Tattnall County11/01/2004

Taylor County12/31/2012

Telfair County10/05/1992

Terrell County07/01/1992

Thomas County05/14/1993

Thomas County Public Library05/23/2011

Tift County02/01/1991

Towns County07/01/1996

Treutlen County07/01/1991

Treutlen County DevelopmentAuthority

10/01/2009

Tri County Joint E-911 Authority01/01/2006

Turner County08/01/1992

Twiggs County11/06/1993

Unified Government ofGeorgetown-Quitman County

10/01/1987

Unified Government of WebsterCounty

04/01/1998

Union County02/11/2002

Upper Oconee Basin WaterAuthority

09/11/1997

Valdosta-Lowndes Co.Conference Center & TourismAuthority

02/23/2000

Valdosta-Lowndes County AirportAuthority

06/04/1995

Walton County07/01/2007

Ware County07/15/1994

Washington County01/12/1988

Washington County AirportAuthority

10/01/2002

Washington County DevelopmentAuthority

10/01/2004

Wayne County10/01/1987

White County07/01/1999

Whitfield County01/01/2003

Wilcox County01/19/2003

Wilkinson County08/03/1993

02/15/2015

GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND Workers’ Compensation

166 Members / January 2016

ACCG 07/01/1982 Appling County 02/24/1983 Atkinson County 07/22/1982 Atkinson County Solid Waste Authority 07/23/1997 Bacon County 09/21/1983 Baker County 05/22/1985 Banks County 09/12/1982 Barrow County 10/15/1992 Bartow County *05/29/1991 Bartram Trail Regional Library System 02/01/2003 Ben Hill County 08/01/1991 Berrien County 01/22/1986 Bleckley County 01/10/1986 Brantley County 03/01/1983 Bryan County 01/29/1983 Bulloch County 07/02/1982 Burke County 08/06/1986 Calhoun County 04/01/1990 Candler County 01/10/1986 Carroll County *05/13/1985

01/01/2002 Carroll County Water Authority

01/23/1989 Catoosa County

05/05/1986 Charlton County

01/01/1986 Chattooga County

02/22/1984 Clay County

12/19/1986 Clinch County

11/04/1988 Coffee County

01/01/2006 Colquitt County

01/01/1983 Columbia County *

06/10/2003 Conyers-Rockdale Library System

04/07/1983 Cook County

01/01/2012 Crawford County

07/05/1985 Crisp County

04/19/1990 Crisp County Power

Cusseta-Chattahoochee Unified Government

03/16/1984

07/05/1985 Dade County

12/30/1982 Dawson County

07/10/1983 Decatur County

05/31/1993 Desoto Trail Regional Library

01/01/2009 Dodge County

10/08/1982 Dooly County

11/13/2009 Early County

Early County Department of Public Safety

10/01/2002

12/01/2007 Eatonton-Putnam Water & Sewer Authority

02/18/1983 Echols County Consolidated Government

09/01/1982 Effingham County

07/01/1982 Emanuel County

04/15/1983 Evans County

04/03/1984 Fannin County

02/19/1993 Flint River Regional Library

04/12/1986 Franklin County

08/29/1982 Gilmer County

02/27/1986 Glascock County

07/01/2012 Glynn County *

06/25/1984 Gordon County

12/19/1986 Grady County

07/02/1982 Greene County

07/27/2004 Greene County Recreation Complex

09/01/2000 Hancock County

10/01/2009 Haralson County

01/01/1990 Harris County Hart County 10/08/1982 Hart County Water & Sewer Utility09/25/2007

01/01/2002 Heard County

03/17/1992 Henry County *

06/01/2002 Henry County Library System

05/11/1995 Housing Authority Of Fulton County

11/20/2009 Irwin County

10/31/1985 Jackson County

02/23/1983 Jasper County

07/14/1986 Jeff Davis County

10/01/2009 Jefferson County

03/01/2008 Jefferson County Library System

04/14/1986 Jenkins County

04/03/1983 Johnson County Jones County 02/26/1983 Lamar County 11/30/1983 Lamar County Solid Waste Authority 01/01/2010 Lanier County 11/30/1983

07/01/1982 Laurens County

05/27/1986 Lee County

09/02/1991 Liberty County

11/07/2015 Lincoln County

07/14/1986 Long County

07/22/1982 Lowndes County *

10/30/2009 Lumpkin County

07/29/1987 Macon County

10/11/1985 Madison County

01/11/1983 Marion County

12/01/1983 McDuffie County

01/01/1994 McIntosh County

08/31/2004 Middle Flint Regional 911 Authority

09/28/1992 Middle Georgia Regional Commission

06/24/1986 Miller County

02/19/1983 Mitchell County

10/08/1982 Monroe County

03/30/1984 Montgomery County

02/25/1983 Morgan County

08/01/2008 Newton County *

02/26/1983 Oconee County

03/22/1993 Oconee Regional Library

01/05/1988 Oglethorpe County

05/13/1985 Paulding County

10/08/1982 Peach County

02/07/1986 Pickens County

11/15/1983 Pierce County

12/31/1983 Pike County Pike County Parks and RecreationAuthority

02/23/2012

Pike County Water & Sewerage Authority

06/01/2008

Polk County 04/09/1985 Polk County Water, Sewage & SolidWaste Authority

08/01/1990

03/01/2002 Pulaski County

07/01/1982 Putnam County

03/12/1983 Rabun County

11/06/2009 Randolph County

07/28/1984 Rockdale County

02/24/1994 Roddenbery Memorial Library

Satilla Regional Water & SewerAuthority

01/01/2002

04/29/1985 Schley County

07/22/1982 Screven County

01/10/1992 Screven-Jenkins Regional Library

06/15/1995 Seminole County

Sinclair Water Authority 01/01/2009 Solid Waste Authority of Crisp County 07/03/2012 South Georgia Regional Library System

04/01/1997

Southwest Georgia Regional Commission

07/01/2004

Spalding County *06/01/2005 Stephens County 01/01/1997 Stewart County 07/20/1988 Sumter County 01/01/1991 Talbot County 12/04/1982 Taliaferro County 07/01/1982 Tattnall County 02/07/1986 Taylor County 04/29/1985 Telfair County 08/01/1984 Terrell County 09/01/1988 Thomas County 07/22/1982 Thomas County Public Library 07/14/1992 Tift County 08/17/1982 Toombs County 04/27/1989 Towns County 10/01/1996 Treutlen County 07/01/1982 Tri County Joint E-911 Authority 01/04/2006 Troup County 12/15/1982 Turner County 02/08/1983 Twiggs County 03/10/1992 Unified Government of Georgetown-Quitman County

06/14/1984

Unified Government of Webster County

04/29/1985

Union County 04/20/1991 Valdosta-Lowndes Co. Conference

Center & Tourism Authority

11/01/2011

Valdosta-Lowndes County Airport Authority

07/01/1995

Walker County 02/01/2002

Walton County *04/01/2001Ware County 06/02/1983Warren County 03/16/1993

Washington County *07/01/1993Wayne County 03/21/1985Wheeler County 10/18/1983

White County 04/29/1985White County Water Authority 11/05/2009Whitfield County *09/01/2002

Wilcox County 02/07/1986Wilkes County 01/01/2013Wilkinson County 08/17/1982

Worth County 04/29/1985

* Large Deductible Member

01/01/2012 Lumpkin County Water & Sewerage Authority

SAFETY DISCOUNT VERIFICATION FORM

INSTRUCTIONS

1. Complete the appropriate SAFETY DISCOUNT VERIFICATION FORM in the booklet.

• The SAFETY DISCOUNT VERIFICATION FORM is also posted on our website.

WWW.ACCG.ORG [MEMBERSHIP SERVICES / INSURANCE PROGRAMS / SAFETY DISCOUNT FORM]

2. Copy a SAFETY DISCOUNT VERIFICATION FORM for each appropriate Insurance Program in which your organization participates.

3. Present the FORM(S) for signature to the County Chairman or an Executive Director of an Authority.

4. Scan & Email, Fax or Mail the applicable SAFETY DISCOUNT VERIFICATION FORM

• Send only 1 copy for each membership in the appropriate Insurance Program • Originals are not necessary

5. Confirmation of Receipt:

Faxed document: Set-up a transmission confirmation receipt using own location's fax

machine.

To Email a scanned attachment: Use the Options tab located at the top of a new email. Request a ‘delivery receipt’ and/or a ‘read receipt’ for evidence of transmission.

U.S. Postal Service Mail delivery: Request a 'signature upon receipt' Form from the

mailman. 6. The application process is complete when the requirements are met and the

SAFETY DISCOUNT VERIFICATION FORM is submitted for each Insurance Program that the organization is a member.

You may submit the SAFETY DISCOUNT VERIFICATION FORM anytime, since the Safety Discount Program is continual throughout the calendar year.

However, the FINAL DEADLINE to submit the ACCG SAFETY DISCOUNT VERIFICATION FORM(S) IS

September 15, 2016.

- 15 -

SAFETY DISCOUNT VERIFICATION FORM

QUESTIONS o Do you know if your organization is a county or an authority?

• ACCG Insurance Programs insures 2 types of members: COUNTIES & AUTHORITIES • County – the largest territorial division for local government within a state

of the United States [Georgia has 159 Counties].

• Authority – A separate entity that provides specific services to their citizens. [Examples are Water & Sewer, Library, Development, Recreation & Housing] Usually ‘AUTHORITY’ is part of the organization’s legal name. County Governments are NOT Authorities. IF YOU DO NOT KNOW - LOOK ON THE MEMBERSHIP LIST (PAGES 13 & 14) CALL YOUR LGRMS FIELD REPRESENTATIVE EMAIL phenderson@accg.org

o Is your organization a member of one or both of the following Insurance Programs?

• ACCG – Interlocal Risk Management Agency (ACCG – IRMA)

[property & liability]

• ACCG – Group Self-Insurance Workers’ Compensation Fund (ACCG – GSIWCF) [workers’ compensation]

IF YOU DO NOT KNOW -

THE ACCG - IRMA & ACCG - GSIWCF MEMBERSHIP LISTS ARE ON PAGES 13 & 14.

o The SAFETY DISCOUNT VERIFICATION FORMS can be sent anytime during the year,

but No Later Than September 15, 2016. • Each applicable form for the appropriate Insurance Program will only need

to be submitted once for the calendar year.

• Copy the forms provided in this booklet or on the website. www.accg.org

• The Safety Discount Verification Form will not be sent in a separate mailing.

- 16 -

INTERLOCAL RISK MANAGEMENT AGENCY

[Property & Liability]

SAFETY DISCOUNT VERIFICATION FORM The members of the Board of Commissioners of ______________ ____ County (Name of County) hereby verify that they fully comply with the requirements of the Safety Discount Program.

______________________________________ ____________________________________ County Chairman Signature Date

The appointed ACCG – IRMA Insurance Contact is __________________________________ (County Contact receives invoices & renewals for property & liability) County Title________________________ Email Address:_________________________

The appointed ACCG – IRMA Safety Coordinator is __________________________ (Safety Coordinator is responsible for the Safety Program) County Title_______________________ Email Address:_______________________ If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the county in order to maintain a current database. Yes No SAFETY COORDINATORS COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)

ATTEND ONE LGRMS TRAINING COURSE __________________________________________ (COURSE / DATE)

Complete this form if your county is a member of the ACCG - IRMA (property & liability) Insurance Program. Send ONLY 1 COPY (if applicable) of EACH SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016.

Send to: Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303

Fax 404-522-1897 / Email phenderson@accg.org or accginsurance@accg.org

- 17 -

COUNTIES [159 COUNTY GOVERNMENTS]

GROUP SELF-INSURANCE WORKERS’ COMPENSATION FUND

SAFETY DISCOUNT VERIFICATION FORM

The members of the Board of Commissioners of ______________ ____ County (Name of County) hereby verify that they fully comply with the requirements of the Safety Discount Program.

______________________________________ ____________________________________

County Chairman Signature Date

The appointed ACCG – GSIWCF Insurance Contact is __________________________________ (County Contact receives invoices & renewals for workers' compensation)

County Title________________________ Email Address:________________________

The appointed ACCG – GSIWCF Safety Coordinator is __________________________

(Safety Coordinator is responsible for the Safety Program)

County Title_______________________ Email Address:_____________________

If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the county in order to maintain a current database. Yes No SAFETY COORDINATORS COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)

ATTEND ONE LGRMS TRAINING COURSE _____________________________________________ (COURSE / DATE)

Complete this form if your county is a member of the ACCG - GSIWCF (workers' comp) Insurance Program. Send ONLY 1 COPY (if applicable) of EACH SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016 .

Send to: Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303

Fax 404-522-1897 / Email phenderson@accg.org or accginsurance@accg.org

- 18 -

COUNTIES [159 COUNTY GOVERNMENTS]

ACCG - GSIWCF

SAFETY DISCOUNT VERIFICATION FORM

The Director of the ________________________________ _______ Authority hereby (Name of Organization) verifies that the organization fully complies with the requirements of the Safety Discount Program. ______________________________________ ____________________________________ Executive Director Signature Date

The appointed ACCG – GSIWCF Insurance Contact is __________________________________ (Authority Contact receives invoices & renewals for workers' compensation) Position_____________________________ Email Address:__________________________

The appointed ACCG – GSIWCF Safety Coordinator is __________________________ (Safety Coordinator is responsible for the Safety Program) Position___________________________ Email Address:________________________ If there is a change in the safety coordinator or insurance contact, please advise if the previous contact is still affiliated with the Authority in order to maintain a current database. Yes No SAFETY COORDINATORS

COMPLETE SAFETY COORDINATOR MODULES I, II, OR III _________________________________ (COURSE / DATE) QUARTERLY SAFETY MEETINGS ____________ ___________ _____________ ____________ 1STQUARTER DATE 2NDQUARTER DATE 3RDQUARTER DATE 4THQUARTER DATE TRAINING (ANY EMPLOYEE)

ATTEND ONE LGRMS TRAINING COURSE _____________________________________________ (COURSE / DATE)

If Member is an authority, send 1 COPY ONLY of THIS SAFETY DISCOUNT VERIFICATION FORM by September 15, 2016.

Send to:

Penny Henderson, ACCG Insurance Programs, 191 Peachtree Street, Suite 700, Atlanta, GA 30303 Fax 404-522-1897 / Email phenderson@accg.org or accginsurance@accg.org

- 19 -

AUTHORITY [NOT A COUNTY GOVERNMENT]

DEFINITION OF AUTHORITY: Separate entities created as a means of providing specific services to their citizens.

EXAMPLES: Water & Sewer, Libraries, and Development Authorities

DIRECTORY

LOCAL GOVERNMENT RISK MANAGEMENT SERVICES 3500 Parkway Lane, Suite 110 • Norcross, Georgia 30092

678-686-6279 • 800-650-3120 Fax: 770-246-3149

Loss Control Operations BECK, DAN Director of Loss Control (Direct Line) 678-686-6280 Email: dbeck@gmanet.com WATTS, DENNIS Training & Communications Manager (Business Cell) 404-821-3974 Email: dwatts@gmanet.com MADDOX, TERESA Office Manager (Direct Line) 678-686-6283 Email: tmaddox@gmanet.com JORDAN, SHAMILLA Administrative Coordinator (Direct Line) 678-686-6282 Email: sjordan@gmanet.com Health Promotion Services ROBINSON, SHEREA Health Promotion Services Manager (Business Cell) 404-821-4741 Email: srobinson@gmanet.com AMOS, CANDACE Health Promotion Services Representative (Business Cell) 404-416-3379 Email: camos@gmanet.com RICHEY, LEIGH Health Promotion Services Representative (Business Cell) 404-295-4979 Email: lrichey@gmanet.com

Field Representatives McINTYRE, JOHN Southeast Georgia Field Representative (Business Cell) 478-954-9035 Email: jmcintyre@gmanet.com RYAN, CHRIS Southwest Georgia Field Representative (Business Cell)229-942-2241 Email: cryan@gmanet.com SHIELDS, STEVE North Georgia Field Representative (Business Cell) 404-416-3920 Email: sshields@gmanet.com SELLERS, NATALIE Central Georgia Field Representative (Business Cell) 404-904-0074 Email: nsellers@gmanet.com Public Safety Risk Consultants EARL, MIKE Southeast Georgia – Public Safety Risk Consultant (Business Cell) 404-558-8525 Email: mearl@gmanet.com HYER, JULIE Southwest Georgia – Public Safety Risk Consultant (Business Cell) 404-615-2420 Email: jhyer@gmanet.com TROTTER, DAVID North Georgia – Public Safety Risk Consultant (Business Cell) 706-491-4015 Email: dtrotter@gmanet.com

- 20 -

www.lgrms.com3500 Parkway Lane • Suite 110 • Norcross, Georgia 30092Phone 678 686.6279 • Toll Free 800 650.3120 • Fax 770 246.3149

Local Government Risk Management Services

Oconee

MurrayWhitfield

Catoosa

Walker

Gordon

Floyd

Pickens

BartowHall

Polk

PauldingCobb

Haralson

Gwinnett

DeKalbWilkes Lincoln

Rock-dale

NewtonMorgan

Walton

Greene

PutnamHancockJasper

Warren

Mc-Du�e

Columbia

Richmond

Glas-cock

Taliaferro

Henry

Clayton

Fulton

Fayette

Coweta

Carroll

Douglas

Heard

Troup Lamar Monroe JonesBaldwin

Upson

Harris Talbot

Taylor

Crawford

Bibb

Muscogee Peach

Twiggs

Wilkinson

Washington

Je�ersonBurke

Johnson

Emanuel

Jenkins Screven

BullochE�ngham

Candler

EvansBryan

TreutlenLauren

Wheeler

Mont-gom-

ery

Toombs Tatnall

Appling

Wayne

Long

Liberty

Chatham

McIntoshBaconCo�ee

Je� Davis

Telfair

Dodge

Wilcox

Pulaski

BleckleyHouston

Dooly

Crisp

TurnerBen Hill

IrwinWorth

Tift

Macon

Schley

MarionChatta-hoochee

Stewart Sumter

Quit-man

Randolph

Terrell Lee

ClayCalhoun Dougherty

Early

Miller

Baker

Mitchell Colquitt

Berrien Atkinson

Seminole

DecaturGrady Thomas Brooks Lowndes

Lanier

Clinch

Pierce

Brantley

Glynn

CamdenCharlton

Echols

Cook

Spalding

MeriwetherPike

Dawson

Web-ster

Butts

Ware

Forsyth

Dade Fannin

Union

Lumpkin

White

TownsRabun

Banks

Stephens

Franklin Hart

Haber-sham

Madison ElbertJackson

BarrowClarke Oglethorpe

Chattooga

Gilmer

Cherokee

Southwestern RegionChris Ryancryan@gmanet.com229.942.2241

Northern RegionSteve Shieldssshields@gmanet.com404.416.3920

Southeastern RegionJohn McIntyre

jmcintyre@gmanet.com478.954.9035

Central Region Natalie Sellers

nsellers@gmanet.com404.904.0074

Field Representative Regions

- 22 -

- 23 -

SAFETY COORDINATOR

RESOLUTION

WHEREAS, ____________________County has agreed to establish the position of Safety

Coordinator to establish and oversee a safety program to assist with the loss prevention efforts of

the county;

WHEREAS, the Safety Coordinator will be responsible for insuring compliance with certain

safety rules and regulations that protect the well-being of county employees and the general

public;

WHEREAS, the Safety Coordinator will be responsible for:

• Establishing and coordinating safety meetings and self inspections to

identify safety related hazards;

• Coordinating and implementing safety rules and training for

supervisors and employees and/or making recommendations to

management regarding such items;

• Reviewing and/or investigating all employee accidents for causes and

making recommendations for improvements and corrections;

• Conducting periodic safety self inspections of all vehicles, buildings,

grounds, equipment and machinery, and work practices and conditions

to determine potential injury exposures;

• Documenting and maintaining inspection records and implementing

any follow up actions; and

Appendix A

- 24 -

WHEREAS, the Safety Coordinator can ensure that qualifications have been met that will

enable the county to receive a substantial discount discounts on their insurance costs.

NOW THEREFORE BE IT RESOLVED that the position of Safety Coordinator is

established for ____________________County.

RESOLVED this ______ day of ________________________, 20____.

BOARD OF COMMISSIONERS OF

__________________ COUNTY, GEORGIA

__________________________, CHAIRMAN

ATTEST:

_________________________________

County Commissioner or Clerk

Adopted: _________________________

Appendix A

- 25 -

MODEL SUBSTANCE ABUSE POLICY

I. Policy Statement

It is the position of ________ that alcohol and controlled substance abuse is a significant health problem in the United States today. The costs involved with this problem include human costs, such as lost jobs, morale problems, injuries, illnesses, and deaths, as well as economic costs, such as property damage, absenteeism, tardiness, lost productivity, increased health insurance costs, and the costs involved in replacing and retraining new employees. Further, in professions that serve the public, alcohol and substance abuse represents a real danger to the health and safety not only of the employees themselves, but also of the constituents served by those employees.

It is the objective of __________ to provide safe and effective public service. To meet this objective, the problem of alcohol and controlled substance abuse must be identified, confirmed and defeated. In order to achieve this, ___________ has developed a comprehensive alcohol and controlled substance abuse policy.

II. Definitions

Within this Substance Abuse Policy, and on any accompanying forms, thefollowing terms shall have the meanings associated therewith:

1) Controlled Substance shall have the meaning and include the substancesdefined as “controlled substances” in the Georgia Controlled Substances Act,O.C.G.A. § 16-13-20 and 16-12-21(4) as said Act shall appear from time totime.

2) Safety Sensitive Position shall be those positions where inattention to duty orerrors in judgment by the employee or applicant while on duty will have thepotential for significant risk of physical harm to the employee, otheremployees or the general public. A list of such positions is attached asExhibit C.

3) Confirmed Positive Result. Whenever an initial test for drugs or alcohol isfound to be positive, the laboratory will carry out additional tests pursuant tolaboratory testing guidelines to confirm that the initial positive indication wascorrect. If the second procedure also indicates the presence of drugs oralcohol, the test result will be considered a confirmed positive result.

4) Medical Review Officer shall mean a properly licensed physician whoreviews and interprets the results of drug tests and evaluates those resultstogether with medical history and any other relevant biomedical informationto confirm positive results.

III. Drug and alcohol use prohibited.

Alcohol and controlled substance use by employees during assigned workinghours, in ___________ buildings or on ____________ grounds, or otherwise while on

Appendix B - 26 -

official business shall be prohibited. This shall include the use or possession of controlled substances, the abuse of prescription medications, the possession of prescription medications by anyone other than the person for whom the medication was prescribed (except as required by official duty), and the use or abuse of alcohol. This prohibition (and the procedures set forth below) is in addition to any other drug and alcohol policy, including any policies or programs required by federal or state law.

IV. Types of testing to be implemented

1) Pre-employment testing: Because substance abuse is not easilydetectible in an applicant without the provision of a drug and alcoholscreening, and because the safety and health of employees and thehealth and safety of citizens depend upon a workforce free from drugand alcohol abuse, all job applicants being considered for employmentin positions for which pre-employment drug and/or alcohol screening isallowed by law, shall be required to pass a drug and/or alcoholscreening test prior to being hired. All job applicants shall be informedin advance that such testing shall be required, and postings for all jobsshall include a notice of this testing requirement. Pre-employmenttesting shall take place only after an offer of employment has beenmade but before employment actually commences.

2) Random and periodic drug testing: Employees in all positionsdesignated as safety sensitive, involved in drug interdiction, or havingunsupervised access to prisoners or contraband shall be required tosubmit to a drug and alcohol screening test at random or on a periodicbasis from time to time as determined by the department head and thepersonnel director.

3) Drug and/or alcohol screening test based on reasonable suspicion:

a. Any employee shall be required to submit to drug and/or alcoholtesting when there is reasonable suspicion to believe that suchemployee is under the influence or effects of drugs and/or alcoholimmediately before, during or immediately after assigned workinghours or while otherwise on duty or in control of government property.

b. Reasonable suspicion means a reasonable belief based on specificobjective and articulable facts and reasonable inferences drawn fromthose facts in light of experience. Situations that may give rise to aconclusion that an employee is under the influence of drugs and/oralcohol include, but are not limited to, the following:

i. An employee is involved in a physical or verbal altercation on thejob.

ii. An employee has an excessive number of incidents or accidents onthe job.

Appendix B - 27-

iii. An employee exhibits unusual behavior such as slurred speech orunsteady walking or movement on the job.

iv. An employee has an odor of alcohol or marijuana on their personon the job.

v. An employee is in possession of alcohol, drugs, or drugparaphernalia on the job.

vi. An employee is observed using illegal drugs or alcohol or hasexhibited the symptoms and manifestations of being impaired dueto alcohol or drug use.

vii. An employee has caused or contributed to an accident while on thejob.

c. In the event a supervisor determines that reasonable suspicion existsthat an employee is under the influence of drugs and/or alcohol, thesupervisor shall immediately report the incident to his/her immediatesupervisor or department head and shall complete the form entitledObservation Checklist (Exhibit A).

d. The determination of whether reasonable suspicion exists shall bemade by the department head or, in his/her absence, by the highestranking supervisory staff on-duty at the time.

e. Following the determination that reasonable suspicion exists, the factsunderlying the determination of reasonable suspicion shall bedisclosed to the employee at the time the demand to submit to testingis made. The employee shall be transported to and from the testingsite by the employee’s supervisor or a designee. Following the testingprocedure, the person transporting the employee shall makeappropriate arrangements to transport the employee home.

f. Supervisors shall be required to document in writing, by the nextworking day, the specific facts, symptoms or observations that formedthe basis for their determination that reasonable suspicion existed towarrant the testing of an employee All documents created inconnection with the determination of reasonable suspicion shall beforwarded to _________________.

4) Testing after accidents or injury: An employee in a safety sensitiveposition, an employee involved in the interdiction of illegal drugs, or anemployee who, in his/her job duties, is given unsupervised custody ofprisoners or contraband shall be subject to a drug and alcohol testconducted when, while on duty or just prior to going on duty:

a. The employee is operating a vehicle and/or equipment causing damageor bodily injury; or

b. The employee is involved in a fatality; or

Appendix B - 28 -

c. The employee is cited with a traffic violation; or

d. The employee sustains a work-related injury requiring medicaltreatment beyond first aid.

V. Prescription drug use

1) Any Employees using prescription medication while on the job shalldo so in strict accordance with medical directions. It is the employee’sresponsibility to notify the prescribing physician of the duties requiredby the employee’s position and to ensure the physician approves theuse of the prescription medication while the employee is performinghis/her duties.

2) The abuse and/or inappropriate use of legally prescribed drugs,including the performance of duties when the employee knows orshould know that he or she is potentially impaired due to prescriptiondrug use, shall be prohibited and shall be deemed a violation of thispolicy. Job performance or attendance deficiencies resulting from useshall be cause for disciplinary action up to and including termination.If any employee’s behavior or job performance gives rise to areasonable suspicion that the employee is abusing or inappropriatelyusing prescription medication, the employee may be required to submitto drug testing and to take leave until such time as the employee iscleared to return to work by the employee’s physician, the MedicalReview Officer, and the personnel director.

3) Employees and job applicants shall at the time of testing provide[Laboratory] with a list of those prescriptions and over-the-countermedications the employee recently has used. The list of medicationsshall be kept confidential until there has been a test result. The list ofmedications shall be disclosed only to the Medical Review Officer whowill determine whether the positive result was due to the lawful use ofany of the listed medications.

VI. Consent

Before a drug and alcohol test is administered, employees and job applicants willbe asked to sign a Consent Form (Exhibit B) authorizing the test and permitting release of test results to the employer and the Medical Review Officer. The consent form shall provide a space for employees and job applicants to acknowledge that they have been notified of the requirements of this policy.

Appendix B - 29 -

VII. Refusal to consent

1) Job applicants: Any applicant for a position for which pre-employmentdrug and/or alcohol screening is permitted by law who refuses to consentto a drug and/or alcohol test shall be denied employment, and anyconditional offer of employment shall immediately be rescinded.

2) Employees: Any employee who refuses to sign the required consent formor to submit to a drug and/or alcohol test as required shall be deemed tohave violated this policy.

3) No show: Employees who fail to appear at the designated collection site tosubmit to a required drug and/or alcohol test when so directed shall bedeemed to have refused to submit to the test shall be deemed to haveviolated this policy. A “no show” shall include any attempt to adulterate atest sample or otherwise frustrate, impair, or otherwise impede the testingprocess.

VIII. Testing laboratory guidelines

1) All testing procedures shall be administered and accounted for by anapproved laboratory and/or medical facility operating in compliance withthe National Institute of Drug Abuse (NIDA) or College of AmericanPathologists (CAP) guidelines.

2) Urine samples shall be provided in a private restroom stall or similarenclosure so that employees and applicants may not be viewed whileproviding the sample, unless circumstances require monitored testing.Outer garments, bags, briefcases, purses, or other containers will not bepermitted into the test area. The water in the commode shall be coloredwith dye to protect against dilution of test samples.

If the drug and/or alcohol test is to be conducted using a specimen otherthan urine (e.g. hair, saliva, blood, etc.), the sample shall be collected in amanner consistent with the privacy of the employee and the need tominimize the possibility of adulteration and/or mislabeling of the sample.

3) Whenever an initial test for drugs and alcohol is found to be positive, thelaboratory will then carry out additional tests pursuant to laboratory testingguidelines to confirm that the initial positive indication was correct. If thesecond procedure also indicates the presence of drugs or alcohol, the testresult is considered a Confirmed Positive Result.

IX. Confidentiality of test results

To the extent allowed by law, all information from an employee’s or jobapplicant’s drug and alcohol screening shall be confidential and only available tothe Medical Review Officer, department head, ____________ and those with a

Appendix B - 30 -

need to know at the discretion of ___________. Disclosure of test results to any other person, agency, or organization shall be prohibited unless written authorization is obtained from the employee or job applicant. In any case, the results of an initial positive drug or alcohol test shall not be released until the results are confirmed.

X. Violations of this policy

Any violation of this policy shall be handled in a manner consistent with disciplinary procedures.

XI. Employee assistance program

Referrals to an employee assistance program or rehabilitation program shall bemade in accordance with established employee assistance policies, if any.

XII. Drug and alcohol convictions

Consistent with the Federal Drug-Free Workplace Act of 1988, employees shallreport to his or her department head within five (5) working days any arrest or conviction made under a criminal drug or alcohol law and any charge made under a drug or alcohol law for which conviction could cause the loss of driving privileges. The department head shall then investigate and make appropriate recommendations to the personnel director.

Appendix B - 31 -

EXHIBIT A ___________________________ OBSERVATION CHECKLIST

Physical Signs or Conditions

1. Walking

___ Stumbling ___ Swaying ___ Staggering ___ Holding On ___ Unable to Walk ___ Unsteady ___ Falling

2. Standing

___ Swaying ___ Sagging at knees

___ Rigid ___ Unable to stand ___ Feet wide apart ___ Staggering

3. Speech

___ Shouting ___ Silent ___ Whispering

___ Slow ___ Rambling

___ Mute ___ Slurred ___ Slobbering ___ Incoherent

4. Demeanor

___ Cooperative ___ Polite

___ Calm ___ Sleepy ___ Crying ___ Silent ___ Talkative ___ Excited ___ Sarcastic ___ Fighting

5. Actions

___ Resisting communications ___ Fighting ___ Withdrawn or improperly talkative ___ Spends excessive amount of time on telephone ___ Displays violent behavior ___ Avoids talking with supervisor regarding work issues ___ Has exaggerated sense of

self-importance

6. Eyes

___ Bloodshot ___ Watery ___ Dilated ___ Glassy ___ Droopy ___ Closed

7. Appearance/Clothing

___ Unruly ___ Messy ___ Dirty ___ Partially dressed ___ Body excrement stains ___ Stains on clothing ___ Having odor ___ Neat

___ Clean

8. Breath

___ Alcoholic odor ___ Faint alcoholic odor ___ No alcoholic odor

9. Accidents

___ Taking needless risks ___ Disregard for safety of others ___ Higher than average accidents

on the job

Appendix B - 32 -

EXHIBIT B PRE-EMPLOYMENT DRUG TESTING

CONSENT AND RELEASE FORM

______________________________

I hereby consent to submit to urinalysis and/or other tests as shall be determined by _____________________ in the selection process of applicants for employment, for the purpose of determining the drug content thereof.

I hereby acknowledge that I have been notified of the requirements the ____________________ Substance Abuse Policy.

I agree that ______________________________________________________________ may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the ______________ for analysis.

I further agree to and hereby authorize the release of the results of said tests to ____________________.

I understand that it is the current use of illegal drugs that prohibits me from being considered for employment with __________________.

I further agree to hold harmless ___________________ and its agents (including the above named physician or clinic) from any liability arising in whole or in part, out of collection of specimens, testing, and use of the information from said testings in connection with __________________ consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.

Applicant: Print Name: _________________________________________ SS# ______________________________

Applicant: Signature: ___________________________________________ Date: ____________________________

Witness Printed Name: ___________________________________________________________________

Witness Signature: ______________________________________________________________________

Guardian Signature (if applicant/employee under 18): __________________________________________

( ) DRUG TEST

( ) BLOOD ALCOHOL

( ) BREATH ALCOHOL

( ) PRE-EMPLOYMENT ( ) CAUSE/REASONABLE SUSPICION ( ) POST-ACCIDENT ( ) RANDOM ( ) FOLLOW-UP TREATMENT ( ) OTHER ________________________

Appendix B - 33 -

EXHIBIT C SAFETY SENSITIVE POSITIONS

______________________________

List Employee Positions which pose a risk of substantial bodily harm during performance of employees' duties or use of equipment provided: (See II Definition #2 on Page 33)

Appendix B - 34 -

SEATBELT POLICY – SAMPLE 1 1. ____________________ County has declared that any and all passengers, including the driver, riding

in a vehicle owned by ____________________ County are required to properly wear installed seat belts

when operating a ____________________ County vehicle.

Exceptions are as follows:

a. Tractors/equipment not equipped with “Roll-Over Protection System” (ROPS)

b. Specialized construction equipment.

c. Prisoners/suspects of law enforcement officers being transported for short distances in the back

seat of the vehicle when restraining devices or other documented circumstances prevent the

proper wearing of seat belts.

d. Other exceptions must be requested in writing giving a full justification. Requests will be

addressed to the [Risk Management/HR/other] Department for approval.

2. Failure to use a seat belt is a serious safety violation and is not to be taken lightly. It is a known fact

that seat belts can and do help reduce the severity of injuries when they are properly used. Proper use

constitutes proper adjustments as well as proper latching of the unit. Employees who receive an auto

allowance or for any other reason for operating their personal vehicle on ____________________ County

business are required to wear their seat belts in their personal vehicles as well as those in

____________________ County vehicles. To bring employees into compliance with this policy:

First Offense: Will result in a written warning;

Second Offense: Will result in a two-day suspension without pay.

Third Offense: Will result in the loss of driving privileges for those who drive

_______________________ County vehicles;

Offense for Those who receive auto allowance: Will be the forfeiture of that allowance.

Appendix C

- 35 -

SEATBELT POLICY – Sample 2 Required Seat Belt Use: ____________________ County values the lives and safety of its employees. It is estimated that

seat belts reduce the risk of death in a motor vehicle crash by 45%, therefore

____________________ County has adopted the following policy concerning employee seat belt usage.

All employees and their passengers are required to use a seat belt when traveling in any vehicle

while in the course of conducting ____________________ County business. The requirement applies to

business travel in a vehicle owned by ____________________ County, in a rental vehicle or in a vehicle

owned by an individual employee, regardless of whether the employee is compensated for the use of

his/her vehicle.

If an employee is provided a county-owned vehicle that is used in the course of his/her

employment and is also available for that employee’s personal use, that employee, together with all

passengers who occupy the vehicle at anytime and for any purpose, whether business-related or

personal, are required to use seat belts at all times the vehicle is in motion.

The use of seat belts is to be considered a condition of employment with this company. Failure to

abide by this stated policy will be considered a breach of that condition of employment and subject the

person in violation to disciplinary action, including suspension and possible termination.

Appendix C

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THE PANEL OF PHYSICIANS What is a posted Panel of Physicians? A posted Panel of Physicians is a list of doctors from whom your employees may seek treatment if injured on the job. Although a minimum of six doctors are to be listed, representing six different medical practices, additional physicians are recommended. All of these doctors are to be updated on the most recent version of the State Board’s Form WC-P1. This is displayed along with the Bill of Rights for the Injured Worker. The Georgia State Board of Workers’ Compensation requires all employers to post these legal-sized documents in a conspicuous area in any location where employees are working. A Spanish version will also need to be posted for Spanish-speaking employees. Who is to be included to ensure a valid Panel of Physicians? A valid Panel of Physicians will comprise of no more than two industrial clinics, and at least one of the doctors listed should represent a minority group. An ophthalmologist and an orthopedic surgeon are also to be included on the Panel. It is recommended that no less than two orthopedic practices be available to enhance the likelihood that the employees are able to obtain an appointment swiftly. Why is a valid Panel of Physicians so important? Besides being required by law, having a valid Panel of Physicians posted at all times is a vital component in controlling the cost of workers’ compensation claims. Employees are required to seek treatment by physicians listed on the Panel. If a valid Panel is not in place at the time of a work-related injury, the employee will no longer be required to seek treatment with those on the Panel. Furthermore, these providers will be familiar with the Employer’s Workers’ Compensation program and be able to treat and closely monitor the employees on a consistent basis. They will be able to offer light duty options when warranted, and will remain committed in returning the employee to work as quickly as possible.

Appendix D

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Frequently Asked Questions How does a valid Panel of Physicians benefit the employer? • A valid Panel of Physicians allows the employer to ensure that its employees are

receiving quality, objective medical care from a physician familiar with Workers’ Compensation, which in turn controls the cost of your Workers’ Compensation claims and helps to minimize your premiums.

Is the employer required to post a valid Panel of Physician? • Yes. It is required by the Georgia State Board of Workers’ Compensation. In the

event that your Panel does not meet the requirements, your employees will be allowed to see any physician they choose. An invalid Panel may jeopardize eligibility for the ACCG Safety Incentive Discount Program.

Is the employer responsible for informing the employees of the posted Panel of Physicians? • Yes. The employees need to know the location of the Panel of Physicians at the time

of hire. They are to be directed to the Panel of Physicians when they are injured and assisted in setting the appointments with the doctors of their choosing.

Must the Panel of Physicians be posted on pink paper? • No. It is recommended that it be posted on pink paper for easy identification, however, there will be no penalty if it is not. Can several doctors from the same practice be placed on the Panel of Physicians? • Yes. However, if several different doctors are listed from one practice, physicians from five other practices will still need to be placed on the Panel. As an alternative, individual practices could be listed instead, and all doctors in that practice would be qualified to treat your employees.

Appendix D

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Should the doctors be contacted that are placed on the Panel of Physicians? • Yes. The physicians will have to agree to be available for the employees under Workers’ Compensation and be familiar with the Light Duty Program. The providers are to be contacted once every six months by the Employer to determine that the doctors are still practicing and accepting the employees. The Panel of Physicians is no longer valid, if even one doctor listed is not available to the employees at any given time. How often does the Panel of Physicians need to be updated? • The form itself needs to be updated whenever the Georgia State Board of Workers’

Compensation revises its documents. The State Board requires that the most recent version of the Panel of Physicians and the Bill of Rights for the Injured Worker be used. The existing Panel will need to be updated any time a change in physician or the medical practice is made.

Do older versions of the Panel of Physicians need to be retained when revisions are made? • Yes. A master copy of each updated Panel of Physicians with the effective date is

to be filed. The particular Panel that was in place at the time of an employee’s injury may need to be referenced.

Does the most recent version of the Bill of Rights for the Injured Worker need to be posted alongside the Panel of Physicians? •Yes. Otherwise, the Panel of Physicians may be deemed invalid. Where may the forms for the Panel of Physicians and Bill of Rights be found? • The website is http://sbwc.georgia.gov and select “Forms.”

ACCG - Claims Administration Services may be contacted at 404-614-2553 or 877-421-6298

Appendix D

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____________________ COUNTY

RETURN TO WORK PROGRAM POLICY: It is the policy of ______________ County to provide and establish a Return to Work Policy for employees with work-related injuries and illnesses who are unable, temporarily and/or permanently, to return to their permanent job duties. Because ___________ County recognizes that their employees are a valued and limited resource, this program is designed to:

• Assist the recovery process by providing a focus and a goal for return of the injured employee.

• Benefit employees by allowing them to return to full wages as soon as possible.

• Benefit employer by reducing workers’ compensation costs.

PROCESS: __________________County will seek return to work opportunities as quickly as medically possible through the use of transitional employment for all employees who are temporarily disabled due to an on-the-job injury. Transitional employment opportunities will be considered in all departments, not just the department in which the injured employee was working. Transitional employment assignments are intended to assist workers who are returning to work after a temporary disability that resulted from a work-related injury. All transitional employment duties must be productive. Duties must never be demeaning or appear worthless in any way. _______________ County, through their reasonable accommodation program, will make efforts to retain employees who are permanently disabled.

SAFETY DISCOUNT:

In compliance with the ACCG – 2016 Safety Discount Program,

________________ County agrees to adopt this Return To Work Policy.

____________________________ _______________________

COUNTY OFFICIAL SIGNATURE DATE

Appendix F

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RETURN TO WORK POLICY

Work Related Injuries or Illness

The County is committed to returning injured employees to work, within safe and healthy medical practices, as soon as practical. As soon as possible after the injury, and when the employee is medically able to return to work, a written medical release from the designated medical service provider must be received by the county personnel department. If the medical release specifies that the employee may return to work, the employee will be returned to work immediately or as soon as practical. The medical release should be on a county-approved PHYSICIAN’S REPORT FORM. The County reserves the right to require any treating physician to review the employee’s job description, including a description of essential duties, and express an opinion as to whether the employee may safely perform the essential job duties, before putting the employee back to work with or without temporary modifications or more permanent accommodations.

Appendix G

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#1234

#1234

#

1234

#

1234

Dept Leader of #2

Dept Leader of #1

Top Elected Official / Administrator /

Manager

Please Print Name Signature

StatusOwner's Name

Department's Risk Reduction Goal

Action Item Owner's Name Target Date Status

#2 Focus DepartmentDepartment's Loss Types Focus

Action Plan

Action Item Target Date

Department's Loss Types Focus

Loss Type

Department

Department's Risk Reduction Goal

#1 Focus Department

% of Claims Dollars

Top Departments by % of Claims Dollars

Top Loss Types by % of Claims Dollars

SAFETY ACTION PLAN

Year:

% of Claims Dollars

Member:

Loss Trend Analysis

Ed. 021016Appendix H

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