121s

Question 1

Employee must notify a supervisor of an injury or illness:

Answer 1

as soon as possible.

Question 2

Employee must complete a 121B and 121C:

Answer 2

within 24 hours.

Question 3

Employee must sign Field Injury File copy of the CHP 121 and CHP 121A:

Answer 3

within 24 hours.

Question 4

Supervisor must provide employee with CHP 600 and CHP 601:

Answer 4

within 24 hours.

Question 5

Supervisor must complete and sign CHP 121 and CHP 121A within 24 hours. Where does the original CHP 121 go?

Answer 5

Original is retained and placed in the employee’s Field Injury File. However, if Nondisabling Injury or Illness, original is sent to SCIF. Also, initiate and sign a SCIF 3301 (if Nondisabling Injury or Illness) and provide to employee.

Question 6

Supervisor must update CHP 442:

Answer 6

within 3 days.

Question 7

Commander or designee must review and sign CHP 121 and CHP 121A:

Answer 7

within 3 days.

Question 8

If illness, Commander or designee must ensure OSHA No. 200 Log is completed:

Answer 8

within 6 workdays. One copy of the CHP 121 is placed in the OSHA 200 Log File.

Question 9

Employee’s CHP 442 is located:

Answer 9

in the employee’s Field Folder.

Question 10

What copies does Division receive and how long do you have to forward?

Answer 10

· CHP 121
· CHP 121A
· CHP 121B
· CHP 121C
· CHP 270, Page 7 (if
applicable)
· CHP 442

Forward within 5 days of injury.

Question 11

What must a employee prepare if there is a status change to a first-aid injury or illness?

Answer 11

A CHP 51, Memorandum, with any medical documentation attached. Must be within 24 hours of the change.

Question 12

When is SCIF notified for a Status Change to First-Aid Injury or Illness?

Answer 12

When medical expenses are incurred. Remove original CHP 121 from Field Folder and forward it with a copy of the CHP 51 to SCIF within 5 days of the change.

Question 13

What must a supervisor prepare for a Status Change to a Nondisabling Injury or Illness?

Answer 13

Initiate SCIF 3301 and provide to employee within 24 hours and prepare a Status Change Comm-Net message.

Question 14

A Comm-Net Message shall be transmitted to Disability and Retirement Unit (DRU) within 24 hours of notification of a:

Answer 14

nondisabling (other than record only or first aid) or disabling occupational injury or illness.

Question 15

The commander or designee shall review the commander’s memorandum and attachment with the employee within:

Answer 15

24 hours of notification of an injury or illness

other than record only or first aid.