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
