Form ADM4728 "Part-Time Employment Calculation Report for Sc or Oil Benefits" - Ohio

What Is Form ADM4728?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADM4728 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADM4728 "Part-Time Employment Calculation Report for Sc or Oil Benefits" - Ohio

1176 times
Rate (4.4 / 5) 59 votes
Instructions for Completing the Part-time Employment
Calculation Report for SC or OIL Benefits
This report must be submitted with all requests for Salary Continuation (SC) or
Occupational Injury Leave (OIL) benefits for employees who were employed part-time for
six weeks prior to the injury.
Complete the employee’s full name
Complete the date of injury
Complete the Bureau of Workers’ Compensation claim # if available
For the 6 weeks prior to the date of injury, capture the employee’s work schedule for every
day of the week, including work hours, regularly scheduled days off and any leave time
taken.
Dates should appear in the small box and time worked or taken should appear in the larger
box (see example below).
5/12
5/13
5/14
5/15
5/16
R
8.0
4.0 PL
R
10.0
4.0 V
ONLY use the codes listed below to document time used
A – Absent, no pay
H – Holiday
R – Regular Day Off
ADM – Administrative Leave
LDW – Last Day Worked
RTW – Date Returned to Work
CT – Comp Time
LOA – Leave of Absence
S – Sick Leave
DL – Donated Leave
OIL – Occupational Injury Leave
SC – Salary Continuation
DOI – Date of Injury
PL – Personal Leave
V – Vacation
For each week, add all hours actually worked and put the total weekly hours in the
last column
Add total weekly hours together to determine total hours for the weeks listed
Input the numbers into the formula below the calendar to determine daily hours of the
part-time employee
The maximum number of hours per week a part-time employee can receive is
39.9 hours. Exceptions may occur the week of the injury.
ADM 4728 (Rev. 12/2018)
Instructions for Completing the Part-time Employment
Calculation Report for SC or OIL Benefits
This report must be submitted with all requests for Salary Continuation (SC) or
Occupational Injury Leave (OIL) benefits for employees who were employed part-time for
six weeks prior to the injury.
Complete the employee’s full name
Complete the date of injury
Complete the Bureau of Workers’ Compensation claim # if available
For the 6 weeks prior to the date of injury, capture the employee’s work schedule for every
day of the week, including work hours, regularly scheduled days off and any leave time
taken.
Dates should appear in the small box and time worked or taken should appear in the larger
box (see example below).
5/12
5/13
5/14
5/15
5/16
R
8.0
4.0 PL
R
10.0
4.0 V
ONLY use the codes listed below to document time used
A – Absent, no pay
H – Holiday
R – Regular Day Off
ADM – Administrative Leave
LDW – Last Day Worked
RTW – Date Returned to Work
CT – Comp Time
LOA – Leave of Absence
S – Sick Leave
DL – Donated Leave
OIL – Occupational Injury Leave
SC – Salary Continuation
DOI – Date of Injury
PL – Personal Leave
V – Vacation
For each week, add all hours actually worked and put the total weekly hours in the
last column
Add total weekly hours together to determine total hours for the weeks listed
Input the numbers into the formula below the calendar to determine daily hours of the
part-time employee
The maximum number of hours per week a part-time employee can receive is
39.9 hours. Exceptions may occur the week of the injury.
ADM 4728 (Rev. 12/2018)
State of Ohio
Part-time Employment Calculation Report for SC or OIL Benefits
This must be submitted with all requests for Salary Continuation (SC) or Occupational Injury Leave
(OIL) benefits for employees who were employed part-time for six weeks prior to the date of injury. Only
completed weeks will be considered. Fax the form to the Third Party Administrator at 614-764-1749.
Date of Injury: ____________________
Employee’s Name:
BWC Claim #: ____________________
Complete the calendar for six (6) weeks prior to the date of injury.
TOTAL WEEKLY
HOURS
SUNDAY
MONDAY
TUESDAY
THURSDAY
FRIDAY
SATURDAY
WEDNESDAY
Total Hours
(for weeks listed)
Total Hours_______________________ divided by _____________# Weeks = ___________________ Average Weekly Hours
Average Weekly Hours ________________ divided by 7 days = ________________ Daily Hours (round to nearest ½ hr)
Daily Hours ______________ is the part-time benefit hours used for this claim
Phone #:
Date:
Signature of Preparer:
NOTICE: Failure to accurately complete a Part-time Employment Calculation Report for part-time employees filing for
SC or OIL benefits may result in a delay of benefits.
ADM 4728 (Rev. 12/2018)
DISTRIBUTION: File / TPA
Page of 2