Date
of Issue: 05/06/2009
Effective
Date: 05/06/2009
Developed
By: Jason Obelenus, Assistant Fire Chief
Issued
by Authority of: Ronald W. Richards, Fire Chief
Ronald
W. Richards
PERSONAL
INJURY REPORTING
Procedure
# 300-09-01
I. Purpose
To establish a standard
operating guideline for documenting an injury at non-emergent or
emergency incidents.
II .Scope
This policy is applicable
to all members of the Browndale Fire Company No.1 who participates in any
fire company activities.
III. Responsibilities
All members are responsible
to report any injuries that occur at non-emergent and emergency incidents.
All company personnel are
responsible to adhere to the procedure established within this policy.
IV. Background information
This procedure identifies
the standard operating guidelines to aid the person or persons involved
injured while participating in company operations and to insure appropriate
documentation and notifications are completed in a timely fashion.
V. Definitions
Officer in Charge-
Highest ranking person that is involved with the incident
Medical Attention-
Any assistance that is given by a 1st Responder, EMT, Paramedic, and/or
Hospital.
VI. Procedures
INJURED PERSON
1. When an injury occurs
the injured person will inform his or her Officer in Charge as soon as
possible.
2. Seek medical attention
if needed.
3. Complete a Workman’s
Compensation Form (see attachment A)
4. Complete a Extraordinary
Report (see attachment B)
OFFICER IN CHARGE
1. Assist the injured person
2. Ensure the workman’s
compensation form and extraordinary reports are completed.
3. Forward the completed
originals to Assistant Chief within 12 hours.
ASSISTANT CHIEF
1. Inform the Fire Chief
2. Start a folder with
Personal Injury Check Off Form (see attachment C)
3. Inform a township supervisor
or designee within 24 hours of injury.
4. Copy of workman’s compensation
form, extraordinary report and any other pertinent paperwork within 72
hours to the township.
5. If needed establish
a Safety Team to collect all facts pertaining to the injury incident.
6. Make formal report for
the Department and fire chief on prevention of another injury.
7. Make yearly updates
on township insurance policy procedures.
VII/ Superseded Policy
This is a new standard
operating guidelines. No prior memos or guidelines on this subject matter
exist.
Attachments:
Attachment A - Workman’s
Compensation Form
Attachment B - Extraordinary
Report Form
Attachment C - Personal
Injury Check Off Form
Browndale
Fire Company No.1
PO Box 10 620 Marion
St. Browndale
Forest City, PA 18421
TEL: 570-785-5300
WORKMAN’S COMPSENATION/INJURY
REPORT
INSTRUCTIONS: Each
member has an employee identification card. It is blue with the yellow
words PIRMA Workers’ Compensation on it. Take the card with you so
that you can present it at the hospital, medical facility, physician or
pharmacy when you are seeking treatment for your Fire Company injury.
The Township Secretary, Lois Terrell, must be notified as soon as
possible after any injury. Home # 785-3416; Township Bldg. #: 785-5937;
fax # is: 785-4774. BOTH the injured party & the Township Secretary
must report accident as soon as possible to insurance company. IT
IS IMPAIRATIVE THAT THE TOWNSHIP IS NOTIFIED AS SOON AS POSSIBLE.
Remember – Your Employer Iis Clinton Township, NOT Browndale
Fire Company.
DATE OF ACCIDENT: _______
TIME OF ACCIDENT: ______ DATE & TIME REPORTED _________
MEMBER’S NAME: ____________________________
SSN:______________________
ADDRESS: _______________________________
DOB :___________________
CITY,ST.,ZIP:_______________________________________________________SEX:____
LOCATION WHERE ACCIDENT
OCCURED:____________________________________________
TYPE OF ACTIVITY : ________________________________________________________________
CARE PROVIDED: _____
NONE REQUIRED ____ REFUSED ____ FIRST AID ____ OTHER
TRANSPORTED TO MEDICAL
FACILITY: __ PERSONAL VEHICLE __ AMBULANCE __ OTHER __
TREATMENT BY PHYSICIAN,
NAME OF PHYSICIAN: _____________________________________
NAME & ADDRESS OF
MEDICAL FACILITY: ____________________________________________
NATURE OF ACCIDENT OR
INJURY: _________________________________________________
CAUSE OF INJURY:
__FALL __STRUCK BY OBJECT __LIFTING __BURNS __ SHARP OBJECT
OTHER/EXPLAIN: _______________________________________________________________________________
ILLNESS/ EXPLAIN : _______________________________________________________________________________
_______________________________________________________________________________
UNSAFE ACT: ___YES
___NO UNSAFE CONDITION: ____ YES
____NO
SEVERITY: ___
DISABLING __ UNKNOWN (FOLLOW UP REQUIRED)
__ NON-DISABLING
__ FATALITY___BRIEF DESCRIPTION OF ACCIDENT: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
RECOMMENDATION FOR PREVENTION
OF RECURRENCE: _______________________________________________________________________________
_______________________________________________________________________________
MEMBER’S EMPLOYER: _________________________________
LOST DAYS/HRS OF WORK:
________________
_______________________________________________________________________________
MEMBER’S SIGNATURE DATE
MEMBER’S TELEPONE #
_____________________________________
CHIEF’S SIGNATURE
DATE
Rev. 05/03/09
PLEASE PRINT CLEARLY
Attachment A
Extraordinary
Incident Report
Browndale
Fire Company
To: Title: ________________________________Date:
_____________ Time: ____________
From: (Name Printed):
Title: Location of Incident: _____________________________
Member Signature: ___________________________________________________________
Type of Incident: __________________________________________
Members Involved Witnesses
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1. Detailed description
of the occurrence.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2. Actions taken.
(list in chronological order)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3. Detailed description
of any injuries.
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Signature of Investigating
Officer: ________________________________________
Date: ___________________________
CC: Chief _____ President:
_____ Assistant Chief _____
Trustees:_____
Captain ____ Chief
Engineer ____ Lieutenant ____ Sergeant ____
Attachment B
BROWNDALE
FIRE COMPANY
PERSONAL
INJURY CHECK OFF FORM
Injury Incident Number:
_____________
Name of Injured Person:_____________________________
INJURED PERSON
___ Inform
Officer in Charge
___ Seek
medical attention
___ Workman’s
Comp Form completed
___ Extraordinary
Report completed
OFFICER IN CHARGE
___ Assist injured
person
___ Ensure all
forms are completed
___ Give originals
to Assistant Chief
ASSISTANT CHIEF
___ Inform
Fire Chief Date________
___ Start a folder
___ Inform Township
Supervisor or designee:
Name______________________
Date________
___ Copy forms
to send to Township Date___________
___ Attach this
form to folder
___ If needed
establish a Safety Team
___ Need yearly
update on insurance from Township Date__________________
Attachment C
