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Personal Injury Reporting
S.O.G. 300-09-01
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 Workmanís Compensation Form (see attachment A)
4. Complete a Extraordinary Report (see attachment B)

OFFICER IN CHARGE

1. Assist the injured person 
2. Ensure the workmanís 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 workmanís 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VII/ Superseded Policy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 - Workmanís 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  
WORKMANíS COMPSENATION/INJURY REPORT

INSTRUCTIONS:  Each member has an employee identification card. It is blue with the yellow words PIRMA  Workersí 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 Ė Your Employer Iis Clinton Township,  NOT  Browndale Fire Company.
 

DATE OF ACCIDENT: _______ TIME OF ACCIDENT: ______  DATE & TIME REPORTED _________

MEMBERíS 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: _______________________________________________________________________________
_______________________________________________________________________________
MEMBERíS EMPLOYER: _________________________________ 

LOST DAYS/HRS OF WORK: ________________

_______________________________________________________________________________
MEMBERíS SIGNATURE DATE     MEMBERíS TELEPONE # 

_____________________________________
CHIEFíS 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
___   Workmanís 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
 

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