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Currency [0]/Explanatory TextB5Explanatory Text  0Good6Good  a1 Heading 1B Heading 1 I}O2 Heading 2B Heading 2 I}?3 Heading 3B Heading 3 I}234 Heading 44 Heading 4 I} 5InputpInput ̙ ??v 6 Linked CellF Linked Cell } 7Neutral<Neutral  e3Normal % 8Noteb Note   9OutputrOutput  ???????????? ???:$Percent ;Title1Title I}% <TotalHTotal OO= Warning Text: Warning Text XTableStyleMedium9PivotStyleLight16`5 To Complete; Supv Example nExample2-complex  ; 5ffH@z@3 A@@  E }PType of Leave UsedSickAnnual Employee: Comp UsedSupervisor/Host Supervisor:Home Department:Last four of GID: Total Hours#Workers' Compensation Time TrackingDate (include year) TOTALS 232 Hour / Time Loss* / Stay-At-Work/Return-To-WorkDescription (e.g., 32-hr. tracking, no work per Dr., Dr. visit/physical therapy, Department where RTW hours were worked, etc.)   John JonesSafety & Risk Management-12340Released to regular job; 2 hrs. physical therapy#Home department disciplinary action.Union negotiations (no annual leave remaining)No transitional work available(Released to regular hours - light duties Hours WorkedRegularSAW/RTWLeave w/o Pay(LWOP) Non-WC Work Comp** SAW/RTW (Stay-at-Work/Return-to-Work) hours are those that the employee is working for MUS but in reduced capacity while healing; also known as transitional work or light duty. Employees working reduced hours/wages are eligible for Temporary Partial Disability (TPD) work comp benefits for a portion of lost wages. There is no waiting period for TPD benefits. Because work status may change, track both TTD and TPD time in the LWOP-WC column.IK Daily Hours 8/14/2017Sally Smith / Host DepartmentVacation leave (prior request)Vacation leaveRegular Hours Comp MUS Benefits 8/10/17Date (with year)"Cumulative Tracked Lost Time (ALL)LWOP 鶹Ƶestern'TTD- Released w/restrictions as of 8/23Restricted work Work Comp (payroll LWOP) Comp Time/Other#Cumulative Tracked Missed Time(ALL)$Doc Appoint.- related to work injury&MSF restrict to 4 hrs/day. SAW/RTW-TPD#%+MSF Rx No Work. Remaining sick leave & LWOP"MSF Rx No Work; using sick leave 2MSF Rx No Work - LWOP & WC (TTD) [32 Hr. Tracking] MSF Rx No Work -TTD:RTW in (Host) department; MSF Rx restricted to 4 hrs./day .4* The claims adjustor pays time loss every two weeks - please submit promptly so your employee receives the timely benefits they are entitled to receive.Not Scheduled (weekend)MSF -No Work MSF No Work3MSF- Light Work, 4 hrs/day- Home Dpt. SAW/RTW (TPD)-$MSF- Light Work, 4 hrs/day -Home Dpt&MSF- Light Work, 4 hrs/day - Home Dpt.MSF - Release to Full DutyMSF- No Work Regular Work-Regular HrsRegular Work & HrsSUBMIT TO CLAIM COORDINATORHome Sprv./Host Sprv:3MSF-No Work (TTD); using sick leave Tracking 32 Hr % *MSF-No Work; using sick leave Track 32 Hr !+MSF-No Work; using sick leave Track 32 Hrs !.MSF-No Work; No Sick Leave Avail. Track 32 Hrs ! "!HOLIDAY Not Scheduled Notes: hSubmit MSFs to Claim Coordinator - they are submitted to WC Claim Examiner for Validation/ReconciliationUDay of Injury should be regular, full pay. 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