Forms Flashcards
What are the six basic forms?
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
What is the Purpose of the Functional Abilities form?
• To identify overall functional abilities and work restrictions that will assist the employee to return to suitable work
If you are in contact with the patient possibly having a communicable disease which form?
• Medical exposure report
You been offer work for three are more days and come back to work what form?
• Medical Assessment Form MAF
What is the Physical Demand Analysis PDA document?
• 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
You coming back to work after a workplace injury what form?
• A Functional Abilities Form FAF
Your injury is not occupational and you are returning to work after 5 days off which form?
• Medical Assessment Form
Why is the Physical Demands Analysis PDA useful for the Dr?
• Useful for the Dr in deciding an appropriate return to work date or modified duties restrictions
You had a workplace injury and are now returning back to modify duties which form?
• The Functional Abilities Form
If you’re injury is occupational which form do you need.
- Functional Abilities Form FAF
* Workplace Injury Illness Report WIIR
What do you do if you receive a significant exposure where a TB patient coughs in your face?
• Complete a Medical Exposure Report • Be assessed by a Dr. Considered a significant exposure • Contact the Designated Officer • Complete a Workplace Injury/Illness Report
You are in contact with hazardous materials at a car fire, house fire or pot on the stove which form?
- Hazardous materials exposure report
* If you see a Dr. You’ll need to fill out the Workplace Injury and Illness Report
You fall at a car accident on some ice, what needs to be filled out?
- WIIR Part A
* OFM Casualty report
You have been off work for 1 shift due to Chest Pain what for are you required to fill out?
• Medical Assessment Form MAF
Any time you see a Dr. after an occupational injury what form must you insure is completed?
• A Workplace Injury and Illness Report WIIR
You are at a house fire and prick yourself with a syringe what forms need to be completed?
• Medical Exposure Report • Hazardous Materials Exposure Report • A Workplace Injury and Illness Report • OFM casualty report
You’re coming back to modify duties after an off the job injury what form is required?
• Medical Assessment Form MAF
If you’ll be off work and not returning due to a work injury how often must you provide the department with this form?
- Functional Abilities Form
- After the 1st doctor’s visits
- Monthly
When are you required to fill out an Office of the Fire Marshal incident and casualty report?
• When the injury results from a firefighter
responding to or
during any incident
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?
- Medical assessment form
* Monthly
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
- Work injury is a FAF
* Non Work injury is A MAF
When are you required to submit Medical Assessment Form?
- 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
You are doing dishes and cut your hand what form do you need to fill out?
• WIIR
If you’re on modified duties are you required to submit a Medical Assessment Form monthly?
- Yes if it is due to a non occupational injury
* Otherwise you have to provide a FAF monthly for occupational injuries
Who is required to complete the Workplace Injury/Illness Report?
• 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
Who should the Workplace Injury and Illness Report be sent to?
• Fire administration
According to the Workplace Injury and Illness Report what does it say is required if this is a critical injury?
• To complete the Workplace Injury and Illness Report and contact the Health and Safety Advisor for MOL notification
What steps are required to complete Part B of the WIIR?
- 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
