HPM 10.7 - INJURY ILLNESS CASE MANAGEMENT

Question 1

Employee report of injury / illness form

Due within ______

Answer 1

CHP 121B (BBBoy I got hurt)

Within 24 hours

Question 2

Medical release of information form

Due within ______

Answer 2

CHP 121C

Within 24 hours

Question 3

Injury/Illness status report form

(Keeps track of who is on 4800 time or off-duty)

Answer 3

CHP 121D

(D LIST)

Question 4

Non Disabling Injury/Illness - employee returns to work when?

Answer 4

The NEXT DAY at full or limited duty, OR is only disabled for the REMAINDER of shift

Question 5

First aid injury /illness - employee returns to work when?

Answer 5

Right away

Question 6

Doctor Predesignation Form

Answer 6

CHP 242

If none on file the employee goes to SCIF

Question 7

Commanders SHALL revoke an employees peace officer powers and retain firearms when they are off duty as a result of _________ issues

Answer 7

Psychological

Question 8

If an injury is questionable? Do you report on 121?

Answer 8

Yes, SHALL report it! SCIF will determine if it will be accepted. Document why you think it’s questionable.

Question 9

Form - Right to privacy form shall be given to employee by sergeant

Within _____

Answer 9

CHP 600

24 hours

Question 10

“Coping with your injury” form

Within _____

Answer 10

CHP 601 - given to employee by Sgt

24 hours

Question 11

Approval for limited duty form. Shall be provided to doctor by Supervisor

Within ______

Answer 11

CHP 443

ASAP

Question 12

Supervisor shall note any CHANGES in injury or illness status on this form.

Within_____

Answer 12

CHP 442

Within 72 hours (3 days)

Question 13

Employee’s fitness plan form - if injury is associated. Attach this to the 121

Answer 13

CHP 270

NOT A VEHICLE ACCIDENT FORM (Opposite)

Question 14

Supervisor shall provide this form to doctor to determine when employee can return to full or limited duty.

When?

Answer 14

CHP 225

ASAP

Question 15

A CHP 121 shall be completed by a supervisor within ___ hours and shall be typed.

Answer 15

24 hours.

Question 16

Employee shall sign 121 within ____ hours.

Answer 16

24 hours

Question 17

Employee’s secondary employment is suspended while on _________ time or ______ time.

Answer 17

4800 time or sick time.

Question 18

Supervisor shall accompany employee to doctor but ______________ when examined. Discuss limited duty with doctor.

Answer 18

Shall not be in the room during exam

Question 19

A recurrence of an old injury shall be documented by the employee on a ____ within ____ hours.

Answer 19

On a MEMO within 24 hours

Question 20

Command shall forward the 121 to _____ within __ days.

Answer 20

SCIF within 5 days

Question 21

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?

Answer 21

Temp command 121 handled by temp command and sent to permanent command for management

Civil disturbance – 121 handled by permanent area

Question 22

Limited Duty assignment is for ___ months. Beyond that, ____ may extend for another 3 months at a time.

MAX time is not to exceed __ years.

Answer 22

Limited duty is for 6 months.

AC Field can extend 3 months each

MAX - 2 years

Question 23

Com-net message should be sent out for disabling injury or non-disabling injury within ___ hours.

Answer 23

24 hours

Question 24

Sergeant provides SCIF 3301 to employee within ____ hours

Answer 24

24 hours

Question 25

A cut, bruise, sprain, exposure, bite, and any other condition attributed to an injury at work is an ____________ injury.

Answer 25

Occupational Injury

Question 26

If the injury does not require first aid or medical treatment - it is a ____________

Answer 26

Record-only injury/illness

Question 27

Do injuries to a job applicant require a CHP 121?

Answer 27

Yes

Question 28

Who completes the memo if the employee is unable?

Answer 28

The supervisor shall complete the memo

Question 29

Academy cadet’s 121 shall be forwarded to assigned command once they _________-

Answer 29

Graduate

Question 30

If employee is unable to sign their 121, what should the supervisor do?

Answer 30

Supervisor should document the reasons why and then have the employee sign when they can

Question 31

If employee refuses to sign the 121, write _________ on the 121

Answer 31

“Refused to Sign”

Question 32

Are supervisors able to contact SCIF directly for case management?

Answer 32

Yes

Question 33

All injury CHP forms are due within 24 HOURS.

Except: (3 forms)

Answer 33

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.