SDFD Injury Report Envelope-2019 Blue Packet (FD-9) Flashcards
How long do you have to report an injury to the “Call-In Center”?
24 hours, however the injury should be reported as soon as possible.
Where do you scan/email the RM-1642? Workers Comp form
Addy Zertuche (azertuche@sandiego.gov) within 24 hours
Medical Status Report for Occupational Injury or Illness (RM-1634)
How many copies are there?
Which copies go where?
3 copies total
White: Risk Mgm’t
Canary: Department
Pink: Employee
Supervisor’s Injury Investigation Report
How many sections on this form and what are they?
There’s four
- Employess Info
- Injury Info
- Exposures
- Explanation of Injury
Workers Comp Claim Form
Whats the form number?
How many sections?
RM-1642
- Employee Section
- Employer section
What form is the one you mark “Employees Temporary Receipt”?
Workers Comp Claim Form
RM-1642
The employer has how long to date this form and provide a copy to the insurer or claims administrator and to the employee within?
one working day
As a reminder, when filling out the Petty Cash Certification Slip (COM5) employees should designate the
________, _______ and ______ they wish the reimbursement to be delivered in the upper right of slip.
battalion, division, and station
*upper right of slip
Employees on IL or Light Duty have how long to return or they will need to complete the Physical Abilities exam and the Return to Operations Checklist?
if gone more than 60 calendar days
An employee may immediately seek treatment from their own physician if a _________________________________form has been completed and is on file with the City’s Risk Management Department at least thirty days “prior” to the injury.
Notification of Election of Personal Physician
RM-1634: MEDICAL STATUS REPORT FOR OCCUPATIONAL INJURY OR ILLNESS FORM:
Employee immediately notifies _________and _______________if there is a change in work status and scan/email’s a copy to ___________________?
- Supervisor and Medical Desk (Addy Zertuche)
- Medical Desk Representative, Addy Zertuche.
How long does the Supervisor’s Accident and Injury Investigation Report kept for?
A minimum of 5 years from the date of injury or illness .
How long do you have to report a Cal OSHA injury resulting in:
- Injury or illness resulted in death
- Injury or illness results in inpatient hospitalization for a period in excess of twenty-four (24) hours
- Loss of any member of the body (amputation of finger, nose,ear, etc.)
- Serious permanent physical disfigurement (severe burns & crushing injury)
8 hours
Operations = BC is suppose to call Cal/OSHA
Straight Days = Direct Supervisor is suppose to contact Cal/OSHA
Who makes the CAL OSHA notification to the Claim Reporting Call-In-Center?
- Operations “BC”
- straight-days (immediate supervisor)
What section on the “Supervisor’s Accident and Injury Investigation Report” does the supervisor fill out?
Sections 1 and 3
After an injury seeking medical attention what is the corrective action that should be taken?
To prevent for injuries?
Cal OSHA requires supervisors to take corrective measures within 24 hours, but we should try immediately and not wait.
Can the Supervisors Accident and Injury Investigative form be shared with Risk Management?
Yes, to ensure care/treatment is provided to the injured employee under the City’s Workers’ Comp Policy.
SDFD Supervisors Accident and Injury Investigative Report:
Where are these forms filed?
The employee’s confidential medical file located in HR.
What are employees suppose to do if they are reporting to LIGHT DUTY?
- Contact their first line supervisor
- Notify HR immediately (within 24 hours)
- Fax a copy of the RM-1634 or scan/email it to Addy Zertuche
- wait for a phone call or email (if you don’t receive either, report in Class B to HR)
*****employees can take AL or report to Light-duty
Who determines the light-duty assignments?
Asst Chiefs (once received from HR)
What form is required after each doctors visit to keep your status updated in HR?
RM-1634 (Medical Status Report)
Who do you contact after hours/holidays to inform the department of your light-duty status?
B1 and Staffing Desk
***Inform them of your change in work status to modified duty status.
What time does the employee need to report for light-duty at HR?
Next business day or Monday at 0730 hours (Class B)
Employees on IL or LD for more than 60 days must complete what?
Return to operations checklist (available in HR)
***contact the IST coordinator to schedule the killer drill.
The completed “Return to operations checklist” needs to be sent to whom?
HR via email
***HR will send a memo to the staffing desk and payroll
If an employee has a workers comp claim on file, can they get free prescription drugs?
Yes, by filling out the “First fill” prescription form
*****this is “first fill” only
Can an employee get workers comp for “mental” as well?
Yes
What form is required at physical therapy appointments?
Medical Status Report for Occupational Injury or Illness (RM-1634)
2019
As a supervisor I am responsible to complete what forms if an employee gets injured or has an illness?
**that require physician’s care
First investigate the employee’s injury or illness, ASAP! Provide recommendations to mitigate the cause. “Better Practice Management”
Supervisor Accident and Injury Investigation Report
2019
How long are the department medical files kept in an employees file?
Minimum of 5 years from the date of the injury or illness.
2019
Injuries or illnesses resulting in medical treatment beyond first aid must be reported to the ____________________________?
Claim reporting Call-in-center within 24 hours
_____________ or the ___________ must contact Cal/OSHA at (800) 321-6742 and report the injury ASAP
BC and first line supervisor (straight-days)
How long does a supervisor have to provide corrective measures after an employee is injured?
24 hours
Who is the provider for work related injuries?
Sharp and Concentra
The City’s authorized providers for medical treatment are _______________________ or ________________________
SHARP Rees-Stealy or Concentra
What’s the Injury Report Envelope number?
FD-9
The City expects supervisor’s to investigate accident/injury’s when?
“As soon as they occur”
What are the employee’s choices for seeking physician care?
Go to Sharp Rees-Stealy Occupational Health Services or Concentra
Go to “Physician of Record”
What is the process for Physician of Record?
Employee must complete the form and file it with Risk Management.
Risk Management must have it on file for at least 30 days prior to injury/illness.
What form requires a time stamp and the arrival/departure time on the form?
Medical Status Report for Occupational Injury or Illness form
RM-1634
For Physical Therapy (ONLY) employee can note up to how many visits on the RM-1634 prior to submitting it to the Medical Desk (Addy Zertuche)
3 visits
Once the supervisor calls the injury or illness in to the Call-In Center, what should they write on the RM-1642 or Workers’ Compensation Claim Form (DWC1) and where?
Write the confirmation number in the top margin.
Are we required to contact Cal-OSHA if an employee is hospitalized for a period in excess of 24 hours for anything “other than” medical observation?
If the employee is being admitted only for “observation” than NO.
If employee is being admitted for “treatment,” in excess of 24 hours, then YES.
What is the criteria to contact CAL-OSHA?
No later than eight (8) hours after the injury/illness was identified if:
- injury or illness resulted in death
- injury or illness results in inpatient hospitalization for a period in excess of twenty-four (24) hours for anything other than medical observation (employee was admitted for treatment)
- employee suffered the loss of any member of the body (amputation including loss of tip of finger, nose, ear, etc.)
- serious permanent physical disfigurement (i.e. severe burns, crushing injury)
*****BC’s must contact CAL-OSHA for OPERATIONS
** First-level Supervisor’s must contact CAL-OSHA
What do you do with the forms of the FD-9 (Injury Report Envelope)?
Once completed, seal the forms in the Injury Report Envelope (FD-9) and return to Medical Desk at MS-604.
What is the employee required to bring to their doctor’s appointments?
RM-1634–Medical Status Report for Occupational Injury or Illness Form
What are considered business hours for employees reporting to modified duty work status?
Monday - Friday (8am - 4:30 pm)
How long does an employee have to contact the Medical Desk (Addy Zertuche) once they have been placed on modified-duty by a physician?
Within 24 hours
Once an employee sends the Medical Status Report to Addy Z, what should they do to hear back?
Check their email. If they do not hear back, report to Headquarters in Class B (by 0730)
