DB 11-02 Injury Prevention And Accountability Program

Question 1

In order to comply with recent State-mandated and Cal/OSHA Workers’ Compensation reporting laws, Form _______ will replace the F-_____ for the reporting of OCCUPATIONAL injury or illness.

Answer 1

Form 5020 replaces F-166A

(Form 5020 and all related forms will be accessible through the Information Portal)

Question 2

What other forms will be used along with Form 5020 to report occupational injury or illness?

Answer 2

-Supervisor’s Accident Investigation Form

-Accident Witness Statement Form

-Worker’s Compensation Claim Form DWC1

-Reviewer Form 5020 Cover Letter

(The Supervisor’s Accident Investigation Form and the Accident Witness Statement Form will be utilized to assist supervisors in completing an accurate and thorough INVESTIGATION of workplace injuries.)

Question 3

Members requesting immediate first care for an injury shall notify their SUPERVISOR who will then contact the _________.

If the member is assigned to an emergency response resource, MFC shall be notified to create an incident.

Answer 3

Medical Liaison Unit.

Question 4

Procedure for when on-duty LAFD member has an EXPOSURE or MINOR TRAUMA:

Answer 4

-MFC shall be notified to create an incident

-F-902M or an ePCR equivalent form shall be completed for injured member

-Member will seek treatment at a facility such as US Health Works or similar treating facility as directed by the Medical Liaison Unit.

Question 5

Procedure for when on-duty LAFD member has injury OTHER THAN EXPOSURE or MINOR TRAUMA:

Answer 5

-Notify MFC to create an incident

-F-902M or an ePCR equivalent form shall be completed for injured member

-RA transport

-EMS Captain SHALL BE attached if member injured meets SECTION 1 of the PRG

-Injured member’s Captain to inform chain of command ASAP

Question 6

For all ranks of injured/ill members below Station/Unit Commander, the investigating officer is the __________.

Answer 6

-Station/Unit Commander

(For Station/Unit Commanders, the investigating officer is the Battalion Commander.)

Question 7

On-duty supervisors shall ensure the following forms are completed for on-duty members who are injured. Upon completion, forms shall be shall be forwarded to the reviewer by ________.

These forms are available online in the IIRS website.

Answer 7

The end of the shift

1. Form 5020 - Electronic submittal, print once approved and forward through channels to reviewer
2. Supervisor’s Accident Investigation Form
3. Worker’s Compensation Claim Form DWC1 - within 24 hours of injury/illness
4. Accident Witness Statement Form (if applicable)

Question 8

Responsibility for completion of the Reviewer Form 5020 COVER LETTER:

For all ranks of on-duty injured/ill members below Station Commander, the reviewer is?

Answer 8

-Battalion Commander

(For Station Commanders, the Battalion Commander is both the investigating officer and the reviewer.)

Question 9

The ___________, assigned to the Risk Management Section, shall be notified AS SOON AS POSSIBLE, and in all cases within _______ of an injury/illness occurrence where PPE or other safety equipment failed or contributed to a member’s injury.

Answer 9

-Department Safety Coordinator

-24 hours

(The SUPERVISOR shall cause the relevant material to be SECURED and/or bagged for later inspection by the Department Safety Coordinator.)

Question 10

The goal of the Injury Prevention and Accountability (IPA) program is to:

Answer 10

-identify causes of injuries and then work to reduce those injuries by increasing awareness and accountability of causes of injuries.