Forms

Question 1

What are the six basic forms?

Answer 1

1) Medical exposure report
2) Hazardous material exposure report
3) Workplace injury illness report WIIR
4) Medical Assessment Form MAF (non occupational injury)
5) Functional Assessment Form FAF (occupational injury)
6) Physical Demands Analysis PDA document

Question 2

What is the Purpose of the Functional Abilities form?

Answer 2

• To identify overall functional abilities and work restrictions that will assist the employee to return to suitable work

Question 3

If you are in contact with the patient possibly having a communicable disease which form?

Answer 3

• Medical exposure report

Question 4

You been offer work for three are more days and come back to work what form?

Answer 4

• Medical Assessment Form MAF

Question 5

What is the Physical Demand Analysis PDA document?

Answer 5

• A document that may be brought to the members Physician went completing Functional Abilities Form or Medical Assessment Form to assist the Physician in understanding the demands of firefighting

Question 6

You coming back to work after a workplace injury what form?

Answer 6

• A Functional Abilities Form FAF

Question 7

Your injury is not occupational and you are returning to work after 5 days off which form?

Answer 7

• Medical Assessment Form

Question 8

Why is the Physical Demands Analysis PDA useful for the Dr?

Answer 8

• Useful for the Dr in deciding an appropriate return to work date or modified duties restrictions

Question 9

You had a workplace injury and are now returning back to modify duties which form?

Answer 9

• The Functional Abilities Form

Question 10

If you’re injury is occupational which form do you need.

Answer 10

• Functional Abilities Form FAF

* Workplace Injury Illness Report WIIR

Question 11

What do you do if you receive a significant exposure where a TB patient coughs in your face?

Answer 11

•	Complete a Medical Exposure Report 
•	Be assessed by a Dr.
Considered a significant exposure
•	Contact the Designated Officer
•	Complete a Workplace Injury/Illness Report

Question 12

You are in contact with hazardous materials at a car fire, house fire or pot on the stove which form?

Answer 12

• Hazardous materials exposure report

* If you see a Dr. You’ll need to fill out the Workplace Injury and Illness Report

Question 13

You fall at a car accident on some ice, what needs to be filled out?

Answer 13

• WIIR Part A

* OFM Casualty report

Question 14

You have been off work for 1 shift due to Chest Pain what for are you required to fill out?

Answer 14

• Medical Assessment Form MAF

Question 15

Any time you see a Dr. after an occupational injury what form must you insure is completed?

Answer 15

• A Workplace Injury and Illness Report WIIR

Question 16

You are at a house fire and prick yourself with a syringe what forms need to be completed?

Answer 16

•	Medical Exposure Report
•	Hazardous Materials Exposure Report
•	A Workplace Injury and Illness Report
•	OFM casualty report
 

Question 17

You’re coming back to modify duties after an off the job injury what form is required?

Answer 17

• Medical Assessment Form MAF

Question 18

If you’ll be off work and not returning due to a work injury how often must you provide the department with this form?

Answer 18

• Functional Abilities Form
• After the 1st doctor’s visits
• Monthly

Question 19

When are you required to fill out an Office of the Fire Marshal incident and casualty report?

Answer 19

• When the injury results from a firefighter
 responding to or
 during any incident

Question 20

If you will be off the job due to a skiing accident you will be off for several months what form are you required to submit and how frequently?

Answer 20

• Medical assessment form

* Monthly

Question 21

After being on modified duty for 4 months when you come back to full duties what form are you required to provide?
Work injury vs. non work injury

Answer 21

• Work injury is a FAF

* Non Work injury is A MAF

Question 22

When are you required to submit Medical Assessment Form?

Answer 22

• 2 (3)or more days off work
• Coming back to modify duties after an off the job injury
• Full duties after an off the job injury
• Full duties after being on modified due to off the job injury
• Back after chest pains

Question 23

You are doing dishes and cut your hand what form do you need to fill out?

Answer 23

• WIIR

Question 24

If you’re on modified duties are you required to submit a Medical Assessment Form monthly?

Answer 24

• Yes if it is due to a non occupational injury

* Otherwise you have to provide a FAF monthly for occupational injuries

Question 25

Who is required to complete the Workplace Injury/Illness Report?

Answer 25

• Section 1-5 on Part A shall be completed by the captain or immediate supervisor
 Within 24 hours

• Part B shall be completed by the PC
 Within two weeks

Question 26

Who should the Workplace Injury and Illness Report be sent to?

Answer 26

• Fire administration

Question 27

According to the Workplace Injury and Illness Report what does it say is required if this is a critical injury?

Answer 27

• To complete the Workplace Injury and Illness Report and contact the Health and Safety Advisor for MOL notification

Question 28

What steps are required to complete Part B of the WIIR?

Answer 28

• PC to conduct an independent investigation
• Discussion with employee and Capt
• Visit he site
• Corrective measures to be discussed
• Complete within 2 weeks
• If it is a Critical Injury include JHSC