10.7, 70.4, Flashcards
Any injury, such as a _____ which results from an occupational incident or exposure involving a single causative event in the work environment. Conditions resulting from _______ are considered to be injuries.
b. Occupational Injury
cut,
fracture,
sprain,
amputation, etc.,
bites, such as insect or snake bites, or from one-time exposure to chemicals
Any _____ or _____, other than one resulting from an occupational injury, caused by exposure to environmental factors associated with employment.
This includes:
I C A I D S
c. Occupational Illness.
abnormal condition or disorder,
acute and chronic illnesses or diseases which may be caused by
inhalation,
cumulative trauma,
absorption,
ingestion,
stress, or
direct contact.
Nondisabling injury or illness which does not require first aid or medical treatment. ____ incidents shall be documented on a ____, Supervisor’s Incident Report-Record Only (refer to Annex A).
d. Record-Only Injury or Illness.
Record-only incidents
CHP 121E
Minor nondisabling injury or illness (splinter, scratch, cut, burn, etc.) which does not involve medical treatment. Record-only and ____ incidents shall be documented on a ___.
e. First Aid Injury or Illness.
First aid,
CHP 121E.
Injury or illness which requires more than first aid, may require more than one-time medical care, and the employee is able to return to work (full or limited duty) following the date of the injury or illness. Examples:
(1) Employee sustains an injury or illness during working hours but completes the assigned work shift.
(2) Employee sustains an injury or illness during working hours and is incapable of completing the work shift due to the injury or illness; however, employee reports to work (full or limited duty) for the next scheduled work shift.
(3) Employee sustains a work-related injury or illness during nonworking hours; however, employee reports to work (full or limited duty) for the next scheduled work shift.
f. Nondisabling Injury or Illness.
Injury or illness which results in an employee being unable to return to work following the date of the injury or illness. Examples:
(1) Employee sustains an injury or illness during working hours and is incapable of reporting to work for the next scheduled work shift or a subsequent work shift due to the injury or illness.
(2) Employee sustains a work-related injury or illness during nonworking hours and is incapable of reporting to work for the next scheduled work shift or a subsequent work shift due to the injury or illness.
HPM 10.7 1-4
g. Disabling Injury or Illness.
Disabling injury or illness which requires overnight hospital care other than for observation, a lengthy disability status, or disability retirement.
h. Serious Injury or Illness.
A _____ of an injury or illness which does not have a new, clearly defined incident to cause injury or illness. It is a spontaneous reappearance of a prior condition.
k. Recurrence of Injury or Illness.
recurrence
______ has an identifiable new incident of injury or illness and shall be processed as a new injury or illness.
An aggravation of an injury or illness
An injury or illness claim for which there is reason to question whether the injury or illness is work-related. Injury and illness claims should not be deemed questionable simply because they are not witnessed or are a result of cumulative trauma. If, based on facts and information obtained during preparation of the employee’s CHP 121, Employer’s Report of Occupational Injury or Illness, there is reason to question whether the injury or illness is work-related, the claim should be deemed questionable pending State Fund’s decision of acceptance or denial. Reasons for questioning the claim shall be documented in detail on the employee’s CHP 121. Any additional supporting documentation shall be attached to the CHP 121.
m. Questionable Injury or Illness.
NOTE: A CHP 121 filed by an employee who is currently under an internal investigation shall be marked “questionable.” The definition of “investigation” can be found in Highway Patrol Manual 10.2, Internal Investigations Manual, Chapter 3, Progressive Discipline. As previously stated, the reason for questioning the claim shall be documented in detail on the CHP 121. It is recommended that this information be placed in Section 35 of the CHP 121. Specifics of the investigation or the subject matter of the investigation shall not be noted on the CHP 121.
- DEATH, SERIOUS INJURY OR ILLNESS. If a death, serious injury, or illness occurs, the commander or designee shall ensure required notifications are made.
a. Telephone Notification. Division and the appropriate Assistant Commissioner shall be notified immediately by telephone. The following persons shall be telephoned in the order listed until one is contacted:
(1) Appropriate Assistant Commissioner.
(2) Executive Assistant to appropriate Assistant Commissioner.
(3) Deputy Commissioner.
(4) Commissioner.
NOTE: In the event contact cannot be made with the appropriate Assistant Commissioner or on-call designee, contact the Emergency Notification and Tactical Alert Center at (916) 843-4199 (see General Order [GO] 100.80, Notification and Report of Emergencies and Unusual Occurrences).
- DEATH, SERIOUS INJURY OR ILLNESS. If a death, serious injury, or illness occurs, the commander or designee shall ensure required notifications are made.
b. An _____ shall be transmitted to the appropriate Assistant Commissioner and DRU within ____ of occurrence (see GO 100.80).
MIS-Web Message. 24 hours
- DEATH, SERIOUS INJURY OR ILLNESS. If a death, serious injury, or illness occurs, the commander or designee shall ensure required notifications are made.
a. Telephone Notification. Division and the appropriate Assistant Commissioner shall be notified immediately by telephone. The following persons shall be telephoned in the order listed until one is contacted:
(1) Appropriate Assistant Commissioner.
(2) Executive Assistant to appropriate Assistant Commissioner.
(3) Deputy Commissioner.
(4) Commissioner.
NOTE: In the event contact cannot be made with the appropriate Assistant Commissioner or on-call designee, contact the Emergency Notification and Tactical Alert Center at (916) 843-4199 (see General Order [GO] 100.80, Notification and Report of Emergencies and Unusual Occurrences).
b. MIS-Web Message. An MIS-Web Message shall be transmitted to the appropriate Assistant Commissioner and DRU within 24 hours of occurrence (see GO 100.80).
c. Reporting to Department of Industrial Relations, Division of Occupational Safety and Health. The Division of Occupational Safety and Health (DOSH) shall be notified by telephone within eight hours. Commands should log into the DOSH website at www.dir.ca.gov/dosh/report-accident-or-injury.html and follow the instructions to find the appropriate Enforcement Office to report the accident.
d. State Fund Notification. State Fund shall be notified by telephone as soon as possible at (888) 782-8338.
- CHP 121, EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS.
a. Completion. CHP 121 shall be completed by the employee’s supervisor within____ of notification of an alleged occupational injury or illness (see Annexes P-1 and P-2).
b. Typed. CHP 121 shall be _____.
c. Employee’s Signature. The employee shall review and sign the field injury file
copy of the CHP 121 within ______ of reporting an injury or illness.
d. Employee’s Inability to Sign. If the employee is incapable of signing the field injury file copy of the CHP 121 within_______ of reporting an injury or illness, the supervisor shall document the circumstances which prevented the signing of the form in the comments section of the CHP 121. The employee shall then sign the form as soon as possible.
f. Commander’s Signature. The commander or designee shall review and sign the CHP 121 within_____ of notification of an injury or illness.
g. Filing With State Compensation Insurance Fund (SCIF). Pursuant to California Labor Code, Section 3760, and the State Administrative Manual, Section 2581.4, the commander or designee shall ensure the CHP 121 (unless ____ or ____) is filed with the appropriate SCIF office within _____of notification of an injury or illness.
h. Delay in Filing With SCIF. Filing of the CHP 121 with SCIF shall not be delayed for any reason. If necessary, the commander or designee shall submit a partially completed CHP 121 to include a statement that additional pertinent information will be forwarded as soon as possible. (SCIF will accept a fax copy pending submission of the completed original.)
24 hours, typed, 24 hours, 24 hours
three days,
record only or first aid without medical expenses incurred, five days
- CHP 121A, SUPERVISORY REVIEW OF OCCUPATIONAL INJURY, ILLNESS OR EXPOSURE.
a. Completion. CHP 121A shall be completed by the employee’s supervisor within _____ of notification of an alleged occupational injury, illness, or hazardous exposure (see Annexes P-3 and P-4).
HPM 10.7 5-2
b. Typed. CHP 121A shall be typed or neatly printed in ink.
c. Employee’s Signature. The employee shall review and sign the field injury file
copy of the CHP 121A within ______ of reporting an injury, illness, or hazardous exposure.
d. Employee’s Inability to Sign. If the employee is incapable of signing the
CHP 121A within ______ of reporting an injury, illness, or hazardous exposure, the supervisor shall document the circumstances which prevented the signing of the form in the comments section. The employee shall then sign the form as soon as possible.
e. Employee’s Refusal to Sign. If the employee refuses to sign the CHP 121A, the supervisor shall type or print “refused to sign” in the employee’s signature block and document the refusal in the comments section.
f. Commander’s Signature. CHP 121A shall be reviewed and signed by the commander or designee within _____ of notification of an injury, illness, or hazardous exposure.
g. Routing. Routing of the CHP 121A shall not be delayed for any reason. If necessary, the commander or designee shall forward a partially completed CHP 121A to include a statement that additional pertinent information will be forwarded as soon as possible.
24 hours, 24 hours, 24 hours,
three days
i. Temporary Assignment. If an injury or illness occurs while an employee is temporarily assigned to another command for reasons other than civil disturbance, the command where the employee is ______ assigned shall be responsible for the completion and filing of the CHP 121 (copy forwarded to the command of permanent assignment). The command where the employee is _____ assigned shall be responsible for subsequent case management.
temporarily,
permanently
j. Temporary Assignment Due to Civil Disturbance. If an injury or illness occurs while an employee is temporarily assigned to another command due to civil disturbance, the command where the employee is ____ assigned shall be responsible for the completion and filing of the CHP 121 and subsequent case management.
permanently,
k. Travel Status. If an injury or illness occurs while an employee is traveling to or from a temporary assignment, the command where the employee is ______ assigned shall be responsible for the completion and filing of the CHP 121 and subsequent case management.
permanently
l. Assignment Outside the Department. If an injury or illness occurs while an employee is temporarily assigned to and/or under the direct control and supervision of an entity other than the Department, the _____ shall be responsible for the completion and filing of the CHP 121 (copy forwarded to command of permanent assignment). The command where the employee is_____ assigned shall be responsible for subsequent case management.
appropriate Assistant Commissioner,
permanently
n. Training at Other Sites. If an injury or illness occurs while an employee is training at other sites, the command where the employee is ____ assigned shall be responsible for the completion and filing of the CHP 121 and subsequent case management.
permanently
- CHP 121C, MEDICAL INFORMATION RELEASE AUTHORIZATION.
a. Employee’s Signature. The employee shall sign CHP 121C within ____ of reporting an injury or illness (see Annex P-6).
24 hours
- CHP 121B, EMPLOYEE REPORT OF INJURY.
a. Completion. CHP 121B shall be completed and signed by the employee within ____ of reporting an injury or illness (see Annex P-5).
24 hours
- CHP 225, CALIFORNIA HIGHWAY PATROL OFFICER TASK STATEMENTS. __________ after notification a uniformed employee sustained an injury or illness requiring medical treatment beyond first aid, the supervisor shall provide the medical care provider with a CHP 225 to assist in determining if the employee may perform full or limited duty (see Annex P-8).
- CHP 270, PAGE 7, FITNESS PLAN. If a reported injury, illness, or hazardous exposure occurred during, or is related to, activities documented on the employee’s previously authorized fitness plan, copies of the plan are to be routed with the CHP 121.
- CHP 442, INDIVIDUAL ACCIDENT, INJURY AND SAFETY RECOGNITION RECORD. Within _______ of initial notification of, or any status change of, an employee injury, illness, or hazardous exposure, the supervisor shall record or update the incident on the employee’s CHP 442 (see Annexes P-9 and P-10).
- CHP 443, APPROVAL OF LIMITED DUTY ASSIGNMENT. _____ after notification of a nondisabling injury or illness which requires assignment of limited duty, the supervisor shall provide the employee’s medical care provider a CHP 443 (see Annex P-11).
As soon as possible,
three days,
As soon as possible,
- CHP 600, RIGHT TO PRIVACY INSTRUCTIONS RELATIVE TO OCCUPATIONAL INJURIES/ILLNESSES AND VEHICLE ACCIDENT REPORTS. Within _____ of notification of an injury or illness, the supervisor shall provide the employee with a copy of CHP 600 (see Annex P-12).
- CHP 601, COPING WITH YOUR INJURY. Within ______ of notification of an injury or illness, the supervisor shall provide the employee with a copy of CHP 601 (see Annex P-13).
24 hours,
24 hours,
- SCIF 3301, EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS.
a. Initiation. SCIF 3301 shall be initiated by the supervisor and provided to the employee within _____ of notification of an alleged injury or illness other than record only or first aid (see Annex P-14).
b. Routing. Completed SCIF 3301s shall be forwarded to SCIF within ______ of command receipt of the forms.
c. Receipt of a SCIF 3301 and/or a Doctor’s First Report of Injury Form. Command receipt of a SCIF 3301 and/or a Doctors First Report of Injury form shall be considered equivalent to employee notification of injury or illness. All applicable injury and illness reporting and routing procedures shall be implemented.
24 hours,
Five days,
- COMM-NET MESSAGE. A Comm-Net Message shall be transmitted to Disability and Retirement Unit (DRU) within _____ of notification of a nondisabling (other than record only or first aid) or disabling occupational injury or illness (see GO 100.80, Report of Unusual Occurrences).
- STATUS CHANGE COMM-NET MESSAGE. A Comm-Net Message shall be transmitted to DRU within _____ of either of the following occurrences:
24 hours,
24 hours,
a. Status Change to Nondisabling or Disabling. A record-only or first-aid injury or illness or hazardous exposure status changes to nondisabling or disabling (see GO 100.80).
b. Status Change of Nondisabling or Disabling. The status of a nondisabling (other than record only or first aid) or disabling injury or illness changes (see GO 100.80).