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14 Cards in this Set
- Front
- Back
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Who do I contact in BAS for help and information regarding on duty injury
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SJFD workers comp liaisons:
Mary L. 408-794-6989 |
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Where do you go after you get cleared for work WITH a doctors note (returning from an on duty injury)
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Go to Fire Admin and see
Mary L. |
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Supervisors steps for injury/incident reporting
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-Notify your supervisor immediately or as soon as practical
-Render 1st aid or medical care for injured employee (they must see a doctor within 24 hours if lost time from work) -Document injury and fill out all 4 documents -Usually everything should be done by the end of shift -JOURNAL ENTRY -Complete/Deliver all documents within 24 hours of reported injury |
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What are the 4 forms that need to be filled out and delivered within 24 hours of a reported injury
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-240-120A: Employee's injury/exposure memo - completed online
-240-120F: SAIR - completed on computer delivered through chain of command to DSO -DWC - 1: Delivered to BC then to SJFD workers comp liaison at Fire Admin -5020: Deliver to BC then to SJFD worker comp liaison at Fire Admin |
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Entry into telestaff after the report of an injury/illness
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Logged as sick time only until the employee returns with a note from the doctor determining the length of time off from work
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Once an employee returns with a note from the doctor determining the length of time off of work, what do we do with that note
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Deliver or FAX to SJFD Workers Comp Liaisons at BAS. They will then modify telestaffing to reflect appropriate disability time
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Returning to work after disability
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Employee MUST report to SJFD Workers Comp Liaisons at Fire Admin - PRIOR to returning to work site to deliver medical release and obtain the BLUE return to work slip for the supervisor
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SJFD Employee's Injury/Exposure report form 240-120A details
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-On computer (goes directly to department data base)
-MUST be completed within 48 HOURS of INJURY -NOT required to be printed out as part of injury packet |
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Supervisors Accident Investigation Report (SAIR) details
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-On computer
-MUST be completed within 48 HOURS of INJURY -Form goes with packet via the Chain of Command to DSO |
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Division of Workers Compensation claim form (form DWC-1) details
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-Employee completes lines 1 thru 8
-Supervisor completes lines 9 thru 17 - Supervisor must provide the employee with DWC - 1 within 24 hours (1 WORK DAY) of reported injury which results in lost time beyond the employee's work shift at the time of injury or medical treatment -Multi Carbon form: White, pink, yellow go to SJFD workers comp liaison within 24 HOURS -Green copy goes to employee |
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State of California Employers Supervisor report of Occupational Inury or Illness form 5020 details
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-Supervisor completes and gives goldenrod copy to employee and delivers to BC for review and delivery to Fire Admin
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Fax number to Workers Comp liaisons at BAS
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408-277-3259
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What if you want to return to duty on a weekend
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-You must have a note from the doctor giving you clearance to return
-You must report to your BC, who will in turn, make a judgement on whether or not you are fit for duty -That following Monday, you must report to Fire Admin with proper documentation for processing |
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What must we do while on disability
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We must call our workers comp liaisons every Monday at BAS to give them a work status report over the phone
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