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Cortland County Department of Fire and Emergency Management 60 Central Avenue Cortland, NY 13045 [PHONE REDACTED] POLICY STATEMENT 100 - 004 REPORTING AND FILING OF INJURIES AND DEATHS March 1st, 2008 PURPOSE: To insure that all injuries and or deaths are properly recorded and forwarded to the appropriate locations. PREFACE: ALL CLAIMS MUST BE FILED WITH THE COUNTY IN A TIMELY MANNER. FAILURE TO COMPLY WILL RESULT IN FINES. IN ADDITION, FILING A VF-2 FORM MORE THAN 10 DAYS LATE IS CONSIDERED A MISDEMEANOR. A fire department officer must sign all forms. Our contact person for claims is Angie Wyatt. She may be contacted at [PHONE REDACTED]. Exact date of injury or death is extremely important. It is imperative that the injury report be filled out the same day that the injury occurred. Under Part 801 of the State of New York Department of Labor Recording and Reporting Public Employees’ Occupational Injuries and Illnesses Section 801.9, Reporting of Fatalities or Multiple Hospitalization Accidents, Within 8 hours after the occurrence of a firefighter accident which is fatal to one or more firefighters or which results in inpatient hospitalization of two or more firefighters, the Fire Chief or his/ her designee shall report the accident to the nearest office of the New York State Department of Labor, Division of Safety and Health, 450 South Salina Street, Syracuse, NY 13202, telephone [PHONE REDACTED]. Whether or not the accident is immediately reportable, if a firefighter dies of the effects of a fire department related accident within 6 months of that accident, the Fire Chief or his/her designee shall report to the Division of Safety and Health office, 315-479- ---PAGE BREAK--- 3212, within 8 hours after learning of such death. Each report required by this section shall relate to the circumstances of the accident, the number of fatalities or hospitalizations, and the extent of any injuries. The Fire Chief or his/her designee shall also provide to the Division of Safety and Health office any additional information and reports concerning the accident as the Department of Labor shall deem to be necessary. If a fatality or serious incident occurs, the Fire Chief or his/her designee shall take appropriate measures to prevent the destruction or alteration of any evidence that would assist in investigating the fatality or serious accident. DEFINITIONS: Political Subdivision - The Fire District shall be listed with the Town put into apprenthesis next to or under it where it asks for Political Subdivision Liable for Benefits. Insurance Company - Cortland County Self Insurance Fund shall be listed where it asks for Insurance Carrier if any. POLICY: STEP 1: PREPARE A RECORD OF ALL ACCIDENTS The law requires all fire districts to keep a record of all injuries sustained by their firefighters in the course of duty. This requirement should be met by completing a VF - 1 form. The VF - 1 is not an insurance form, but rather a method of keeping an internal record of all accidents. This form should be completed after any accident. If a claim for benefits is made at a later date, this form should be submitted with that claim to: Angie Wyatt County Attorneys’ Office 60 Central Avenue Cortland, NY 13045 ---PAGE BREAK--- Example: A firefighter falls down and bruises his knee. He does not wish to receive any medical attention. A VF - 1 Form should be filled out and kept on file in case the condition worsens and he does require medical attention at a later date. Anytime it is believed that a member of the department may have been exposed to but not limited to chemicals, a hazardous substance, or transmitted diseases, and does not receive medical treatment that would result in a medical bill, a VF - 1 Form shall be filled out. STEP 2: REPORT OF ACCIDENT OR INJURY In addition to completing a VF - 1, the following forms may be necessary. All claims must be filed with Angie Wyatt. VF - 2: This form is the actual report of loss to the Cortland County Self-Insurance Program. The County cannot set up a claim unless they have a signed and completed VF - 2. Failure to file this form within ten (10) days is a misdemeanor. A VF – 2 and the New York State Department of Labor Injury and Illness Report (form SH 900.2) shall be completed for the following injuries and illnesses: a. any accident or injury in which a volunteer firefighter requires medical treatment beyond ordinary first aid and medical bills results from such treatment. b. death c. loss of consciousness d. days away from work e. restricted activity f. any significant work-related injury or illness that is diagnosed by a physician or other licensed health care professional g. any work-related case involving cancer, chronic irreversible disease, a fractured or cracked bone, or punctured eardrum ---PAGE BREAK--- h. any needle stick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material i. tuberculosis infection as evidenced by a positive skin test or diagnosed by a physician or other licensed health care professional after exposure to a known case of active tuberculosis. The original VF - 2 form as well as the original VF 1 form must be forwarded to the County. A copy of this form will be retained by the fire department as well as one for the injured member. STEP 3: CLAIMS FOR BENEFITS FOR LOST TIME AT WORK If a volunteer firefighter loses time from work and is due reimbursement, the following form must be filed with the County. VF - 3: This form must be filed, in addition to a VF - 2 form, if the accident or injury is one in which a volunteer firefighter loses time from his/her regular employment. This form should be filed immediately. The original VF - 3 form as well as the original VF 1 and VF 2 forms must be forwarded to the County. A copy of this form will be retained by the fire department as well as one for the injured member. STEP 4: DEATH CLAIMS In the case a firematic injury should result in the death of a volunteer firefighter, the following forms should be filed with the County within 90 days. VF - 62: the fire district following a line of duty death of a firefighter must complete this form. C - 64: This form is proof of death. It must be completed by the physician last in attendance of the deceased. C - 65: This form is proof of burial and funeral expenses. It must be completed by the mortician. The County’s insurance company will assist with the proper filling out of ---PAGE BREAK--- all these forms. STEP 5: NON AFFILIATED FIREFIGHTERS If a volunteer firefighter from another fire department volunteers his or her services during an emergency and such services (other than mutual aid) are accepted by the officer in charge, then such firefighter, if they are injured in the line of duty, is covered under the host Fire Department’s VFBL Coverage. This includes firefighters from outside Cortland County. It is the Host Fire Department’s responsibility to fill out the necessary forms on these individuals if they are injured. Volunteer firefighters of other municipalities responding under mutual aid remain covered under their own jurisdiction, and are not the responsibility of the department requesting the mutual aid. STEP 6: FILING OF FORMS Once the appropriate forms have been filled out, they will be distributed to the following locations: 194655468. Copy for the member for his personal record keeping 194655469. Original VF 2 and VF 3 Forms will be forwarded to: Angie Wyatt County Attorney’s Office 60 Central Avenue Cortland, NY 13045 [PHONE REDACTED] If VF 2 and VF 3 Forms need to be submitted to the County Attorney’s Office then the original VF 1 form also needs to accompany these forms. ISSUED BY FIRE COORDINATOR Robert Duell