INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT

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1 INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT I. GENERAL SECTION : Information to be placed in this section only by County Risk Management personnel. The General section of the Workers Compensation- First Report of Injury contains eleven- (11) fields. Some of these fields already have information placed in them. 1. Employer (Name & Address, include Zip)- Completed field. (Washington County Volunteer Fire & Rescue Assoc. 100 W. Washington Street, Room 251, Hagerstown, MD 21740). 2. Carrier/Administrator Claim Number- To be completed by County Risk 3. Report Purpose Code- To be completed by County Risk 4. Jurisdiction- To be completed by County Risk 5. Jurisdiction Claim Number- To be completed by County Risk 6. Insured Report Number- To be completed by County Risk 7. SIC Code- To be completed by County Risk 8. Employer FEIN- Completed field. ( ) 9. Employer s Location Address (If Different)- To be completed by County Risk 10. Location #- To be completed by County Risk 11. Phone #- To be completed by County Risk II. CARRIERS / CLAIMS ADMIN : Information to be placed in this section only by County Risk Management personnel. The Carriers / Claims Admin section of the Workers Compensation- First Report of Injury contains seven- (7) fields. Some of these fields already have information placed in them. 1. Carrier (Name, Address & Phone No)- Completed field. (Selective Inc. Co) 2. Policy Period- - To be completed by County Risk 3. Claims Administrator (Name, Address & Phone No)- To be completed by County Risk 4. Carrier FEIN- - To be completed by County Risk 5. Policy / Self-Insured Number- Completed field. (WC ) 6. Administrator FEIN- To be completed by County Risk Management 7. Agent Name & Code Number- Completed field. (CBIZ)

2 III. EMPLOYEE : The Employee section is to be completed by the Chief of Department, employee. The Employee section of the Workers Compensation- First Report of Injury contains thirteen- (13) fields. Some of these fields already have information placed in them. All information in this section needs to be accurate for proper processing. 1. Name (Last, First, Middle)- This is the last, first and middle name of the injured employee. For example; Walker, Frederick, Thomas. 2. Date of Birth- Date of birth of injured employee. For example 04/23/ Social Security Number- Social Security Number of the injured employee shall be place in this field. For example Date Hired- Entry date into the department or membership date. For example 01/01/ State of Hire- Completed field. (MD) 6. Address (Including Zip)- This is the home address of the injured employee. 7. Sex- Check the appropriate field box of the injured employees gender. 8. Marital Status- Check the appropriate field box of the injured employees marital status. 9. Occupation / Job Title- Completed field. (Firefighter) 10. Employment Status- Completed field. (Active) 11. Telephone (Include Area Code)- This is a reliable contact number for the injured employee. For example # Of Dependents- The number of dependents the injured employee has. 13. NCCI Class Code- Completed field. (7704). IV. WAGE : Leave the Wage section of the report blank, except for the Volunteer completed field. 1. Rate- Completed field. (Volunteer) 2. Day/ Month/ Week/ Other- Do not check any of these boxes. 3. # Days Worked / Week- Leave field blank. 4. Full Pay for Day of Injury?- Do not check any of these boxes. 5. Did Salary Continue?- Do not check any of these boxes.

3 V. OCCURRENCE : The Occurrence section is to be completed by the Chief of Department, employee, injured employees Group/Division Supervisor or Incident Commander. The Employee section of the Workers Compensation- First Report of Injury contains twentyfour- (24) fields and shall be completed entirely. All information in this section needs to be accurate for proper processing. 1. Time Employee Began Work- This shall be the exact time of an alarm, station detail/ activity, fund raising event; ect For example, 8:30. Do not use military time. 2. AM / PM- Check the appropriate box indicating AM/ PM for the time employee began work. 3. Date of Injury/Illness- The exact date of the employees injury/illness. For example 02/19/ Time of Occurrence- The exact time the injury occurred to the employee. For example 8:47. Do not use military time. 5. AM / PM- Check the appropriate box indicating AM/ PM for the exact time the injury occurred to the employee. 6. Last Date Worked- This date shall be the last date the injured employee worked for the employer. This is not the date of injury. For example, the injured employee completed a station detail on 02/17/2012. While working an alarm on 02/19/2012, the employee injured his right ankle requiring medical care. The Last Date Worked is 02/17/ Date Employer Notified- This date shall be the exact date of the employee injury. For example, 02/19/2012. Remember, all injuries shall be reported immediately to a department officer! 8. Date Disability Began- Unless this is a re-occurring injury, this date shall be the exact date the employee received injury. For example, 02/19/ Contact Name/ Phone Number- This is the name and a reliable phone number of the injured employee. For example, Frederick Thomas Walker / Type of Injury/Illness- Specify the type of injury/illness that the employee received. For example, possible sprained/ broken right ankle. 11. Part of Body Affected- Specify the body part affected by the injury. For example, right ankle / foot. 12. Did Injury/Illness Exposure Occur on Employers Premises- Check Yes if injury occurred on department property. Check No if injury did not occur on department property. 13. Type of Injury/Illness Code- Leave this field blank. To be completed by County Risk 14. Part of Body Affected Code- Leave this field blank. To be completed by County Risk 15. Department or Location Where Accident or Illness Exposure Occurred- This is the exact location (try to use a physical mailing address) where the employee was injured or became ill. You can be as specific as a division/ floor, side and quadrant, roof; ect. Along

4 with an address, you can also place a county incident number in this field as well. For example, Twin Circle, Somewhere, MD 22222; County Incident # All Equipment, Materials or Chemicals Employee Was Using When Accident or Illness Exposure Occurred- Be as specific as possible as to what you place in this field. For example, employee was utilizing full firefighter turnout gear, full SCBA with face piece, radio and haligan bar. 17. Specific Activity the Employee Was Engaged In When the Accident or Illness Exposure Occurred- Be as specific as possible as to what you place in this field. This is the activity the employee was performing when the injury or illness occurred. For example, employee was performing search and rescue techniques in a 2 nd floor bedroom, located on side Charlie, delta quadrant. 18. Work Process the Employee was Engaged In When Accident or Illness Exposure Occurred- Be as specific as possible as to what you place in this field. This is the activity the employee was performing when the injury or illness occurred. For example, employee was performing search and rescue techniques in a 2 nd floor bedroom, located on side Charlie, delta quadrant. 19. How Injury or Illness / Abnormal Health Condition Occurred. Describe the Sequence of Events and Include Any Objects or Substances That Directly Injured the Employee or Made the Employee Ill- Be as specific as possible as to what you place in this field. This is the activity and sequence of events the employee was performing when the injury or illness occurred. For example, employee was performing search and rescue techniques in a 2 nd floor bedroom, located on side Charlie, delta quadrant in an IDLH atmosphere. The employee was reaching / swiping a tool under a bed when the employee felt a pop in his right shoulder and upper back area. 20. Cause of Injury Code- Leave this field blank. To be completed by County Risk 21. Date Return to Work- This is the date the employee is allowed to return back to work. If a return date is unknown, then place N/A for not applicable in the field. For example, 02/19/2012 or N/A. 22. If Fatal, Give Date of Death- Exact date of fatal occurrence. For example, 02/19/ Were Safe Guards or Safety Equipment Provided- Check the appropriate Yes or No box. 24. Were They Used- Check the appropriate Yes or No box.

5 VI. VII. TREATMENT - The Treatment section can to be completed by the Chief of Department, employee, injured employees Group/Division Supervisor, Incident Commander, On-Scene Medical Provider or Hospital Staff. The Treatment section of the Workers Compensation- First Report of Injury contains three- (3) fields and shall be completed, if information is readily available. All information in this section needs to be accurate for proper processing. 1. Physician/Health Care Provider (Name & Address)- This can be the attending physician who treated the injured employee at a medical facility or an On-Scene Medical Provider (ERT, EMT, Paramedic) who provided medical care to the injured employee. If no treatment took place, then write No Treatment in the field box. 2. Hospital (Name & Address)- Hospital name and physical address where injured employee was transported. If no transport took place, then write No Transport in the field box. 3. Initial Treatment- Check the appropriate box indicating medical treatment. OTHER The Other section is to be completed by the Chief of Department, Department Safety Officer or County Safety Officer (ISO-II) with assistance of the injured employee, injured employees Group/Division Supervisor or Incident Commander or any witnesses. The Other section of the Workers Compensation- First Report of Injury contains five- (5) fields and shall be completed entirely. All information in this section needs to be accurate for proper processing. 1. Witness (Name & Phone #)- If there were any witnesses to the employees injury, place their name and a reliable phone number in this field box. If no witnesses, place No Witnesses in the field box. 2. Date Administrator Notified- This is the exact date as to when the administrator was notified. This date is usually the date the injury occurred or when the Workers Compensation- First Report of Injury is completed and submitted to the County Risk Manager. 3. Date Prepared- This is the exact date is to when the Workers Compensation- First Report of Injury is completed and submitted to the County Risk Manager. 4. Preparer s Name & Title- This is the name and title of the officer completing the Workers Compensation- First Report of Injury. 5. Phone Number- This is a reliable phone number of the officer completing the Workers Compensation- First Report of Injury.

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