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Home My WebLink About106.015 - FC-06, Supervisor's Report of Injury ADMINISTRATIVE MANUAL FORMS 106.015 SUPERVISOR’S REPORT OF INJURY (FC-06) EFFECTIVE: JUNE 2008 Current Revision Date: 04/26/21 Next Revision Date: 04/26/24 Author’s Name/Rank: Brad Dandridge, Battalion Chief Review Level: 1 Administrative Support: Evelyn Yin-Zepeda, Management Analyst II PURPOSE This policy ensures proper documentation of all injuries sustained during the course of employment with the City of Fresno (City) Fire Department (Department or FFD). APPLICATION This report is utilized by the company officer or immediate supervisor to document an on-the-job injury or illness incurred by a member during the course of his/her employment with the City. This form is to be used for all injuries. OPERATIONAL POLICY This report will be utilized whenever an on-the-job injury occurs and will be submitted for: Injury/Infectious Exposure – Immediately after a job-related injury has occurred and no later than the end of the day or shift in which the injury occurred. Illness – Within 24 hours after a licensed medical doctor has diagnosed the illness to be job related. Exception: In certain cases, a Supervisor’s Report of Injury should be completed prior to a physician’s diagnosis of a job-related illness. This includes incidents where a member has been exposed to potentially hazardous environmental factors associated with his/her employment. Exposure may include inhalation, absorption, ingestion, or direct contact. OPERATIONAL GUIDELINE It is the member's responsibility to notify his/her immediate supervisor of any injury or illness incurred while on duty. It is the company officer's or the immediate supervisor's responsibility to submit a properly completed Supervisor's Report of Injury form no later than the end of the day or shift in which the injury occurred. PROCESS A Supervisor's Report of Injury should be completed by the company officer or immediate supervisor when the following events occur: A member is injured during the course of his/her employment. A licensed medical doctor diagnoses the member to have a job-related illness. A member is exposed to potentially hazardous environmental factors during the course of his/her employment. This would include, but not limited to, exposure to contagious diseases, toxic chemicals, dusts, gases, or fumes. Procedures A completed FC-06, with a completed Administrative Manual Section 106.018, Medical Service Order (MSO). Occupational Health Provider List, Form FC-11 and FC-17 (if applicable), should be submitted through the Department’s Records Management System (RMS) prior to the end of the shift in which the injury occurred. In the event this option is not available, forms may be accessed through the File Center / Manuals, Procedures, and Forms in (Learning Management System). The completed forms may be scanned and sent electronically, or hand delivered to the Safety and Wellness Office at Headquarters. Note: Telephone contact with the Safety and Wellness Officer at Headquarters should be attempted prior to sending any electronic communications to ensure both parties are aware notification is occurring in this manner. Instructions The Supervisor's Report of Injury should be completed as follows: Access the form in the RMS / Favorites Tab / Select FF Injury. Select from the dropdown menu where the injury occurred: Incident or Other. Note: If Incident is selected, enter the incident number and submit for validation. Complete all appropriate fields of the FC-06 and submit when completed. Accident Information – Complete the following boxes with relevant Section 106.015 Page 2 of 6 information describing the accident. Fully describe what the member was doing at the time the injury occurred (e.g., pulling ceiling, forcing entry, conducting primary search), include all essential information (who, what, where, when, and why). Note: If the injury or illness occurred during an emergency incident, include the incident number. Describe exactly how the injury occurred. Indicate the circumstances surrounding the occurrence (e.g., while participating in a multi-company drill; while returning from a false alarm; during fire suppression activities at Incident No. xxx). Identify tools, equipment, or materials the member was using. Describe object or substance that directly injured the member (i.e., the ceiling collapsed on the member's head; the pike pole went through the member's foot; the member stepped on a steel splinter in the debris; the vapor or toxin inhaled; the chemical that irritated his/her skin; or the object he/she was lifting, pulling, etc.). Enter a brief but descriptive explanation of the injury, illness, or type of exposure, and the part of the body affected (e.g., laceration on right forearm, pneumonia, exposure to hepatitis, inhalation of petroleum fumes). Contributing Factors – Complete the following boxes with relevant information describing the accident. o If the injured employee has returned to work and there was NO TIME LOST. Indicate NO TIME LOST after “DATE RETURNED”. Note: When a member receives medical treatment, a Medical Service Order (MSO) (FC-11) and, if appropriate, an Employee’s Claim for Workers’ Compensation Benefits (FC-17), must be completed and submitted in conjunction with this report. o The supervisor should list any actions personally taken to prevent similar accidents. The supervisor may electronically sign and date the report. Note: If “w/comp” is selected for the “type of injury” a completed FC-11 and FC-17 will be automatically generated. A completed FC-06, FC-11 and FC-17 will be generated and electronically sent to the Safety and Wellness Officer at Headquarters and injured worker. Section 106.015 Page 3 of 6 If the Department’s Records Management System is unavailable, access the FC-06 through the File Center in LMS and follow the directions above. Provide a copy to the injured worker and forward a copy to the Safety and Wellness Officer at Headquarters. Distribution Submit a copy to the Safety and Wellness Office at Headquarters and a copy to the injured worker. Reference Job Code Number Job Classification City of Fresno FIRE 130012 Accountant-Auditor II 125012 Computer Systems Spec III 720031 Equipment Supervisor 115003 Executive Asst to Dept Dir 425005 Fire Battalion Chief 425004 Fire Captain 425007 Fire Chief 425006 Fire Deputy Chief 420012 Fire Equipment Mech Lead 420011 Fire Equipment Mechanic II 425010 Fire Investigation Unit Sup 210055 Fire Prevention Engineer 420002 Fire Prevention Inspector II 425002 Firefighter 425003 Firefighter Specialist Job Code Number Job Classification City of Fresno FIRE 425001 Firefighter Trainee 150021 Management Analyst II 150022 Management Analyst III 130004 Principal Account Clerk 125022 Programmer/Analyst III 150065 Project Manager 810006 Property Maintenance WII 110003 Senior Admin Clerk 110051 Senior Secretary 145002 Senior Storeskeeper 420003 Sr Fire Prevention Insp. 145001 Storeskeeper 420005 Supv Fire Prevention Insp. 150046 Training Officer Section 106.015 Page 4 of 6 INFORMATION This section intentionally left blank. DEFINITIONS This section intentionally left blank. CROSS-REFERENCES Administrative Manual Section 106.018, Medical Service Order (MSO). Occupational Health Provider List (FC-11) Section 106.020, Employee Claim for Workers’ Compensation Benefits (FC-17) Section 110.002, Appropriate Level of Care for On-the-Job Injuries (OJI) Section 110.003, On-the-job Injury (OJI) Reporting Section 106.015 Page 5 of 6 □ □ I □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ I □ □ I □ □ 1 □ □ □ FC-06 SUPERVISOR’S REPORT OF INJURY/INCIDENT EMPLOYEE NAME: DEPARTMENT: DIVISION: JOB CLASSIFICATION: PEOPLE SOFT EMPLOYEE ID NO.: JOB CODE NUMBER: HOME ADDRESS OF INJURED EMPLOYEE: SEX: MALE FEMALE BIRTHDATE: / / SUPERVISOR’S WORK PHONE: EMPLOYEE HOME PHONE: CELL PHONE: SUPERVISOR’S NAME: ACCIDENT INFORMATION DATE OF ACCIDENT/ONSET OF ILLNESS: BODY PART(S) AFFECTED: WORK SHIFT HOURS: START: END: DAYS OF WEEK: TIME OF INJURY: AT CITY FACILITY? YES NO DESCRIBE THE CONDITIONS OR CIRCUMSTANCES WHICH CAUSED THIS ACIDENT TO OCCUR (WHAT, WHEN, AND HOW). PLEASE BE SPECIFIC. Use additional paper if necessary. WAS THE EMPLOYEE PERFORMING DUTIES IN THE COURSE & SCOPE OF THEIR EMPLOYEMENT? YES NO WHEN MAKING REPORT, DID YOU USE THE FOLLOWING: WITNESS STATEMENTS POLICE REPORT # PHOTOS TAKEN OTHER (EVIDENCE) WHAT WAS THE CAUSE OF THE ACCIDENT THAT DIRECTLY INJURED THE EMPLOYEE? CONTRIBUTING FACTORS (Check all that apply) Improper work technique Servicing equipment in motion Improper maintenance Inattention Safety rule violation Horseplay Failure to warn or secure Defective equipment/tools Improper PPE or PPE not used Poor workstation design Lack of direct supervision Other / Unsure (specify): Inadequate guards or protection Poor housekeeping Insufficient training Improper lifting Physical condition, weather Improper dress or apparel HAS EMPLOYEE RETURNED TO WORK? YES NO DATE RETURNED: AFTER REVIEW OF ALL FACTS, WHAT WAS THE HAZARDOUS CONDITION, UNSAFE WORK PRACTICE OR OTHER ROOT CAUSE OF THE INJURY/INCIDENT? WAS FIRST AID GIVEN? YES NO WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT? YES NO DID EMPLOYEE GO TO THE DOCTOR? YES NO IF YES, NAME AND ADDRESS OF DOCTOR OR CLINIC. DO YOU CONCUR WITH THE EMPLOYEE’S ACCOUNT OF THE ACCIDENT? YES NO UNSURE IF NO OR UNSURE, PLEASE EXPLAIN: WHAT IS RECOMMENDED TO PREVENT THIS TYPE OF INCIDENT/ACCIDENT FROM OCCURING AGAIN? SUPERVISOR’S SIGNATURE: Date: DIVISION MANAGER SIGNATURE: Date: Section 106.015 Page 6 of 6