HPM 10.7 - INJURY ILLNESS CASE MANAGEMENT Flashcards
Employee report of injury / illness form
Due within ______
CHP 121B (BBBoy I got hurt)
Within 24 hours
Medical release of information form
Due within ______
CHP 121C
Within 24 hours
Injury/Illness status report form
(Keeps track of who is on 4800 time or off-duty)
CHP 121D
(D LIST)
Non Disabling Injury/Illness - employee returns to work when?
The NEXT DAY at full or limited duty, OR is only disabled for the REMAINDER of shift
First aid injury /illness - employee returns to work when?
Right away
Doctor Predesignation Form
CHP 242
If none on file the employee goes to SCIF
Commanders SHALL revoke an employees peace officer powers and retain firearms when they are off duty as a result of _________ issues
Psychological
If an injury is questionable? Do you report on 121?
Yes, SHALL report it! SCIF will determine if it will be accepted. Document why you think it’s questionable.
Form - Right to privacy form shall be given to employee by sergeant
Within _____
CHP 600
24 hours
“Coping with your injury” form
Within _____
CHP 601 - given to employee by Sgt
24 hours
Approval for limited duty form. Shall be provided to doctor by Supervisor
Within ______
CHP 443
ASAP
Supervisor shall note any CHANGES in injury or illness status on this form.
Within_____
CHP 442
Within 72 hours (3 days)
Employee’s fitness plan form - if injury is associated. Attach this to the 121
CHP 270
NOT A VEHICLE ACCIDENT FORM (Opposite)
Supervisor shall provide this form to doctor to determine when employee can return to full or limited duty.
When?
CHP 225
ASAP
A CHP 121 shall be completed by a supervisor within ___ hours and shall be typed.
24 hours.
Employee shall sign 121 within ____ hours.
24 hours
Employee’s secondary employment is suspended while on _________ time or ______ time.
4800 time or sick time.
Supervisor shall accompany employee to doctor but ______________ when examined. Discuss limited duty with doctor.
Shall not be in the room during exam
A recurrence of an old injury shall be documented by the employee on a ____ within ____ hours.
On a MEMO within 24 hours
Command shall forward the 121 to _____ within __ days.
SCIF within 5 days
If an employee gets hurt at a temporary command, who handles 121?
If employee gets hurt at a civic disturbance in another command, who handles 121?
Temp command 121 handled by temp command and sent to permanent command for management
Civil disturbance – 121 handled by permanent area
Limited Duty assignment is for ___ months. Beyond that, ____ may extend for another 3 months at a time.
MAX time is not to exceed __ years.
Limited duty is for 6 months.
AC Field can extend 3 months each
MAX - 2 years
Com-net message should be sent out for disabling injury or non-disabling injury within ___ hours.
24 hours
Sergeant provides SCIF 3301 to employee within ____ hours
24 hours
A cut, bruise, sprain, exposure, bite, and any other condition attributed to an injury at work is an ____________ injury.
Occupational Injury
If the injury does not require first aid or medical treatment - it is a ____________
Record-only injury/illness
Do injuries to a job applicant require a CHP 121?
Yes
Who completes the memo if the employee is unable?
The supervisor shall complete the memo
Academy cadet’s 121 shall be forwarded to assigned command once they _________-
Graduate
If employee is unable to sign their 121, what should the supervisor do?
Supervisor should document the reasons why and then have the employee sign when they can
If employee refuses to sign the 121, write _________ on the 121
“Refused to Sign”
Are supervisors able to contact SCIF directly for case management?
Yes
All injury CHP forms are due within 24 HOURS.
Except: (3 forms)
CHP 442 (3 days) - Changes to injury or illness status
CHP 443 (ASAP) - Approval for limited duty. Provided to doctor by Supervisor
CHP 225 (ASAP) - Given to doctor. When employee can return to full work / limited duty.
