FIRST REPORT OF INJURY



THE BALTIMORE COUNTY VOLUNTEER FIREMEN’S ASSOCIATION24460207747000700 East Joppa Road – 3rd Floor Phone: (410) 887-4885Towson, MD 21286 Fax: (410) 832-8507 Email: bcvfa@Effective Monday, July 1, 2013, Mercy Medical Center will be the designated Baltimore County Employee Health Clinic, instead of Concentra. One location will be utilized:Lutherville Personal Physicians1734 York Road (corner of York and Ridgely Roads)Lutherville, MD 21093443-275-5090Hours of Operation: 0800 – 1600, Monday through FridayThis facility is to be used for random drug testing.When outside of the Employee Health Clinic’s operating hours, utilize Saint Joseph Medical Center as the primary care facility, or the closest appropriate hospital.Worker’s Compensation – now being handled by Baltimore CountySupervisor’s Report of Injury will need to be filled out when there is an injury on the job. The form will need to be faxed to Baltimore County / Worker’s Compensation Unit at (410) 832-1516 as well as the Volunteer office at (410) 832-8507. You will also need to call in the injury to Worker’s Compensation at (410) 887-6565. If after hours, please leave a message as to the person injured, date, time, etc. Baltimore County Workers Compensation UnitOffice of Human Resources308 Allegheny AvenueTowson, MD 21204PH#: 410-887-6565228600-114300001600200685800FIRST REPORT OF INJURY00FIRST REPORT OF INJURYBALTIMORE COUNTY VOLUNTEERFIREMEN’S ASSOCIATIONVolunteer:____________________Vol. Station:_____________________Date/Time of Injury:___________Name of Employee:___________________________________________SSN_______________________Accident Location:_______________________________________Date/Time Start Work:______/_____ FORMCHECKBOX AM FORMCHECKBOX PMJob Title:________________________________DOB:__________SEX: M FORMCHECKBOX F FORMCHECKBOX Date Hired:_______Employee Status:Full-time FORMTEXT ?????, Part-time FORMTEXT ?????Date/ Time Supervisor Notified: FORMTEXT ?????, FORMTEXT ?????HOMEADDRESS________________________________________________Marital Status:Street_________________________________________Phone: _______________M FORMCHECKBOX S FORMCHECKBOX CityStateZipAccident Category, Check Type FORMCHECKBOX Motor Vehicle FORMCHECKBOX Equipment FORMCHECKBOX Employee Injury FORMCHECKBOX Property DamageIf Motor Vehicle Accident – Give Police Report No.______________________________________Vehicle Number – 10 digit (on door of vehicle):___________________Fuel Card Number – 5 digits:____________Type of Injury/ Illness/ Body Part:__________________________________________________________________________Describe Accident:_______________________________________________________________________________________List equipment, materials or chemicals employee used when accident / illness occurred:_______________________________________________________________Cause of the accident:_____________________________________________________________________________________Corrective action taken to prevent a recurrence: _________________________________________________________________________________Medical Treatment by:Name____________Address_________________Date__________Time______Witness:Name _____________________________________Phone __________________________________Safety equipment used at time of accident? FORMCHECKBOX Yes FORMCHECKBOX NoAdditional Comments:___________________________________________________________________________________ FORMTEXT ????? FORMTEXT ?????Supervisor’s Name (PRINT)Date FORMTEXT ?????Supervisor’s SignaturePhone NumberFAX TO: BALTIMORE COUNTY WORKER’S COMPENSATION (MS 45) FAX NUMBER (410) 832-1516 REV: 7-1-13Call claim info in at (410) 887-6565. If no one answers, please leave a message with date, time, person injured, hospital (if applicable) and then fax form to (410) 832-1516 and also Volunteer Office at (410) 832-8507. ................
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