HPM 10.7 Chapters 5-7

Question 1

1. 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).
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Answer 1

24 hours (5-1, 1-a

Question 2

2. The ______ shall review and sign the field injury file copy of the CHP 121 within 24 hours of reporting an injury or illness.

Answer 2

Employee (5-1, 1-c)

Question 3

3. If the employee refuses to sign the field injury file copy of the CHP 121, the supervisor ________ type or print “refused to sign” in the employee’s signature block and document the refusal in the comments section.

Answer 3

Shall (5-1, 1-e)

Question 4

4. 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 record only or first aid without medical expenses incurred) is filed with the appropriate SCIF office within ___________ of notification of an injury or illness.

Answer 4

Five days (5-1, 1-g)

Question 5

5. 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 _____________ ____________ 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 permanently assigned shall be responsible for subsequent case management.

Answer 5

Temporarily assigned (5-1, 1-i)

Question 6

6. If an injury or illness occurs while an employee is traveling to or from a temporary assignment, the command where the employee is ___________ __________shall be responsible for the completion and filing of the CHP 121 and subsequent case management.

Answer 6

Permanently assigned (5-2, k)

Question 7

7. If an injury or illness occurs while an employee is training at other sites, the command where the employee is ___________ ___________shall be responsible for the completion and filing of the CHP 121 and subsequent case management.

Answer 7

Permanently assigned (5-2, n)

Question 8

8. CHP 121A shall be completed by the employee’s ___________ within 24 hours of notification of an alleged occupational injury, illness, or hazardous exposure (see Annexes P-3 and P-4).

Answer 8

Supervisor (5-2, 2-a)

Question 9

9. CHP 121A _______ be typed or neatly printed in ink. 


Answer 9

Shall (5-3, b)

Question 10

10. CHP 121B shall be completed and signed by the _________ within 24 hours of reporting an injury or illness (see Annex P-5).

Answer 10

Employee (5-4, 3-a)

Question 11

11. If the employee is incapable of completing and signing the CHP 121B within 24 hours of reporting an injury or illness, the supervisor shall document the circumstances which prevented completion and signing of the form in the comments section of the CHP 121A. The employee shall then complete and sign the CHP 121B________________.

Answer 11

As soon as possible (5-4, 3-b)

Question 12

12. As soon as possible after notification a uniformed employee sustained an injury or illness requiring medical treatment beyond first aid, the ____________ 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).

Answer 12

Supervisor (5-5, 6)

Question 13

13. Within _______ days 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).

Answer 13

Three (5-5, 8)

Question 14

14. Within __________ of notification of an injury or illness, the supervisor shall provide the employee with a copy of CHP 600 (see Annex P-12).

Answer 14

24 hours (5-6, 10)

Question 15

15. 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).

Answer 15

24 hours (5-6, 12-a)

Question 16

16. A ___________ Message shall be transmitted to Disability and Retirement Unit (DRU) within 24 hours 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).

Answer 16

Comm-Net (5-7, 15)

Question 17

17. Departmental policy directs __________ to ensure that employees receive prompt and proper medical care if such care is deemed necessary by either management or the employee.

Answer 17

Commanders (6-1, 1-a)

Question 18

18. State Administrative Manual, Section 2582, directs that each agency must post a complete STD 621, Notice to State Employees, at state offices and places of state work in a ___________ location (see Annex P-21).

Answer 18

Conspicuous (6-2, 2-a)

Question 19

19. Employees desiring to __________ a treating physician for an industrial injury must fill out a CHP 242, Employee Predesignation of Treating Physician (available on FormFlow) (refer to Annex P-28).

Answer 19

Predesignate (6-2, 4-a)

Question 20

20. If an employee fails to predesignate a medical care provider and/or facility prior to the reported injury or illness, the employee ______ be directed by the command to a provider and/or facility within the MPN.

Answer 20

Shall (6-3, b)

Question 21

21. _________________ directs that an employee shall be physically and psychologically capable of performing the essential duties of his/her employment classification.

Answer 21

Departmental policy (7-1, 1-a)

Question 22

22. A ____________-ordered FFD examination is a medical examination performed by a physician chosen by the Department to determine an employee’s ability to perform the essential duties of his/her employment classification.

Answer 22

Department (7-1, 1-a-1)

Question 23

23. A ________-initiated medical examination may be requested if the employee has a previous or current related occupational injury or illness claim on file with SCIF.

Answer 23

SCIF (7-1, 1-a-2)

Question 24

24. A __________ shall notify his/her commander when the supervisor becomes aware an employee is suffering from any condition which might limit the employee’s physical or psychological ability to perform the essential duties of his/her employment classification.

Answer 24

Supervisor (7-5, 4-a)

Question 25

25. An ___________ conveniently experiences a flare-up of a previous injury or illness requiring the employee to be placed off duty subsequent to being counseled or disciplined for poor work performance.

Answer 25

Employee (7-6, 5-f)