FSJC Employee Work Related Injury Checklist

• Site conducted

  Select

• Conducted on

  Date

• Inspected By

• Accompanied By

• Location
  Address

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• Has the supervisor been notified?

  Yes

  No

  N/A

• Has the safety manager been notified?

  Yes

  No

  N/A

• Has the chosen physician been verified to determine if they are/are not enrolled with FECA?

  Yes

  No

  N/A

• Has the incident been entered into e-safety (within 2 days)?

  Yes

  No

  N/A

• Has the work being performed and actions leading to the injury been explained in plain language?

  Yes

  No

  N/A

• Was this an injury and was a CA-1 created? <br>Notes: <br>• COVID exposures are entered as an injury<br>• COVID case/exposures should list wildland firefighters and EMTs as emergency responders in the e-Safety

  Yes

  No

  N/A

• Was this a diagnosed work-related illness and was a CA-2 created?

  Yes

  No

  N/A

• Was this a recurring injury or illness and was a CA-2a created?

  Yes

  No

  N/A

• ? If a claim was filed, COP was requested.

  Yes

  No

  N/A

• Has the supervisor certified the incident within 2 days, signed the form, had the employee sign the form, and faxed it to ASC?

  Yes

  No

  N/A

• Is all medical paperwork (diagnoses, work restrictions, etc.) uploaded into e-Safety?

  Yes

  No

  N/A

• Has the supervisor contacted ASC for a CA-16?

  Yes

  No

  N/A

• Has the case manager’s name and contact information been received?

  Yes

  No

  N/A

• Was the CA-16 provided to the physician?

  Yes

  No

  N/A

• Was the physician contacted to ensure the CA-16 was received, completed and returned?

  Yes

  No

  N/A

• Does the medical documentation contain a diagnosis, clearly links the injury/illness to work, and states start and end dates for any required Restricted Duty or Days Off Work?

  Yes

  No

  N/A

• Has the CA-1, CA-2, or CA-2a been printed from e-Safety, signed, and faxed to FS-WC at 1-866-339-8583?

  Yes

  No

  N/A

• Have you contacted Forest Service Workers Comp for a DOL claim number? Call your FS case manager for your claim number if needed.

  Yes

  No

  N/A

• Has the OWCP File Number received from FS-WC case manager and provided to all medical providers/facilities?

  Yes

  No

  N/A

• Has the supervisor been given a copy of the written physician order for required Days Off Work or Restricted Duty Days?

  Yes

  No

  N/A

• Has the employee been advised that all injury/illness related paperwork is kept by the employee?

  Yes

  No

  N/A

• Has the supervisor been advised that all employment related paperwork is kept by the supervisor?

  Yes

  No

  N/A

• Has a physician's work release been provided to supervisor and your FS-WC case manager when the employee is ready to return to work?

  Yes

  No

  N/A

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