Chesapeake Fire Department Accident Reports & Forms PDF

Procedure 701 Chesapeake Fire Department Fire Procedure Manual Copyright Lexipol, LLC 2023/03/25, All Rights Reserved.Published with permission by Chesapeake Fire Department Accident Reports & Forms - 1 Accident Reports & Forms 701.1 PERSONAL INJURY ACCIDENT REPORT All personal injuries, no ma...

Procedure 701 Chesapeake Fire Department Fire Procedure Manual Copyright Lexipol, LLC 2023/03/25, All Rights Reserved.Published with permission by Chesapeake Fire Department Accident Reports & Forms - 1 Accident Reports & Forms 701.1 PERSONAL INJURY ACCIDENT REPORT All personal injuries, no matter how seemingly minor, which have occurred on the job and result in illness or injury to an employee must be immediately reported. This includes exposure to communicable diseases. The "Chesapeake Fire Department Accident/Loss Report" should be completed for all personal injury, illnesses, exposures experienced by the member. In addition to the initial Accident Report, the member’s supervisor must also complete an Authorization for Medical Treatment form Information on the reports must be complete and accurate and the employee’s immediate supervisor must review all accidents. It should be noted in the space provided on the Accident/ Loss Report if any corrective action has been or will be taken to prevent recurrence. The report is to be signed by the supervisor regardless of whether corrective action is taken. The employee must complete the appropriate section of the "Authorization for Medical Treatment" form even if he/she is refusing treatment. If the member is requesting medical treatment, a listing of city approved physicians is provided on the reverse side of this form.The attending physician must be on the City's list of approved physicians. The member must take the form to the physician or emergency room,have the physician provide the diagnosis and prognosis on the form and then return to the Health and Safety Officer with the accident report attached. NOTE : It is extremely important for the Battalion Chief to notify the Accounting Office if an employee’s injury will involve lost time. Leave will not be charged for time lost on the date of the injury. If loss of time is involved, sick leave will be charged beginning the day after the injury through the seventh day. The employee will be placed on worker's compensation beginning on the eighth day after the injury.If the employee is out for more than twenty-one days, any sick leave charged will be reinstated. Under the provisions of Administrative Regulation 21.6, an employee may use sick or annual leave to supplement the worker's compensation pay. If the employee chooses to supplement their pay by using leave, a Workers’ Compensation Supplemental Leave Request must be requested from the Accounting Division, signed and returned to the as soon as possible. Any member requiring additional treatment following the initial examination should obtain a written statement from the physician advising the department of the diagnosis, treatment plan and prognosis for recovery. All written statements are forwarded to the Health and Safety Officer immediately. After treatment for either an on-the-job or off duty injury, the injured member must obtain a written letter from the attending physician providing a statement of the member’s prognosis and the estimated time frame for return to duty. If the member was injured on the job and is to be released Chesapeake Fire Department Fire Procedure Manual Accident Reports & Forms Copyright Lexipol, LLC 2023/03/25, All Rights Reserved.Published with permission by Chesapeake Fire Department Accident Reports & Forms - 2 for selective duty, the Health and Safety Officer must be notified and will determine light duty opportunities and assign personnel as appropriate. Prior to returning to a full-duty status, the member’s attending physician must provide a written letter stating that the member may return to full duty without restriction. 701.2 VEHICLE ACCIDENT REPORTS When a City vehicle is involved in an accident, the driver of the vehicle must complete a "Chesapeake Fire Department Accident/Loss Report" completing all the blanks that pertain to the specific incident. The employee's immediate supervisor must review the accident and provide comments in the appropriate place on the reverse of the form to include “corrective action taken or that will be taken to prevent reoccurrence”. The form is then forwarded to the Department’s Safety Officer along with an "Automobile Loss Notice".(A sample of this form is provided at the end of this SOP.) If the accident involves another vehicle, the driver must obtain the information required in the section "Property Damage" of the “Automobile Loss Notice” completing all of the spaces in the section. If the accident involves property other than the Fire Department vehicle, this section must be completed and a description of the property damaged (i.e. mailbox, etc.) included when it is returned to the Department’s Safety Officer. Estimates from the City Garage for the damage to the City owned vehicle should accompany the accident report whenever possible or should be sent to the Fire Chief's office as soon as possible. All reports must be signed and dated in all the appropriate places and returned to the Department’s Safety Officer within 24-hours of the accident. 701.3 EQUIPMENT/PROPERTY LOSS When city equipment or property is damaged or a loss is involved, the responsible party must complete a “Chesapeake Fire Department Accident/Loss Report”completing all blanks that pertain to that specific incident. The employee’s immediate supervisor must review the incident and provide comments in the space provided on the reverse side of the form. Comments should include corrective action taken or action that will be taken to prevent reoccurrence. When completed, the form is forwarded to the department’s Safety Officer along with a “Property Loss Notice”. All information pertaining to the incident must be completed. All reports must be signed and dated in the spaces provided and forwarded to the department’s Safety Officer within 24-hours of the incident/loss.