ࡱ> BDAq` |GbjbjqPqP ,Z::$:::tD|X$2|xxx; H1111111$4h61u:m$"m$m$1xmX2a1a1a1m$8x:1a1m$1a1a1":a1| TU(0a11n202a1J7,J7a1J7:a1\!h!Ja15"<q"!!!11Q1!!!2m$m$m$m$$ Nbp WASHINGTON VOLUNTEER FIREFIGHTERS & RESERVE OFFICERS RELIEF AND PENSION FUND REPORT OF ACCIDENT REPORT OF INJURED MEMBER Name of department  FORMTEXT       Date of Accident  FORMTEXT       Name of injured member  FORMTEXT       Birthdate  FORMTEXT       M  FORMCHECKBOX  F  FORMCHECKBOX  Address of member  FORMTEXT       Phone #  FORMTEXT       Regular occupation  FORMTEXT       Social Security Number  FORMTEXT       Single  FORMCHECKBOX  Married  FORMCHECKBOX  Full Name of Spouse  FORMTEXT       Children under 18 supported by you: Name:  FORMTEXT       Birthdate:  FORMTEXT       Name:  FORMTEXT       Birthdate:  FORMTEXT       Name:  FORMTEXT       Birthdate:  FORMTEXT       Name:  FORMTEXT       Birthdate:  FORMTEXT       Activity at the time of the accident:  FORMCHECKBOX  Responding to:  FORMCHECKBOX  At scene:  FORMCHECKBOX  Returning from:  FORMCHECKBOX  Training:  FORMCHECKBOX  Other activity:  FORMCHECKBOX  aid call  FORMCHECKBOX  aid call  FORMCHECKBOX  aid call  FORMCHECKBOX  at academy  FORMTEXT        FORMCHECKBOX  fire  FORMCHECKBOX  fire  FORMCHECKBOX  fire  FORMCHECKBOX  at station  FORMTEXT        FORMCHECKBOX  patrol  FORMCHECKBOX  patrol  FORMCHECKBOX  patrol  FORMCHECKBOX  at live fire  FORMTEXT        FORMCHECKBOX  other  FORMTEXT        FORMCHECKBOX  other  FORMTEXT        FORMCHECKBOX  other  FORMTEXT        FORMCHECKBOX  other  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Describe the accident in full:  FORMTEXT        FORMTEXT        FORMTEXT       I hereby authorize any hospital, physician or other person who has attended me or examined me to furnish to Board for Volunteer Firefighters and Reserve Officers any and all information with respect to any accident or illness, medical history, consultation, prescriptions or treatment, and copies of hospital or medical records. A photocopy of this authorization shall be considered as effective and valid as the original. Witness: X _______________________________ SIGN HERE X_____________________________ Date:  FORMTEXT & * , @ B D N P R |     " 6 8 : D F H N ¾ylj\hV>*UjhV>*UjthV>*UjhV>*UmHnHujhV>*UjhV>*U hV>*hVhVCJOJQJh4"ThV5OJQJhVCJ OJQJ&jhVCJOJQJUmHnHuhVCJOJQJ*p 0  hj @  df!(@@@@dh (@ P(@@dh] <(@@dh $@@dh (@@:dh]:$a$$ (@a$2GzGN P l n p z |      * , 0 V Z \ p r t ~    βإβؘβ؋βjhVUjhV>*UjhV>*Uj,hV>*UjhV>*UmHnHujhV>*UjhV>*U hV>*jDhVUjhVUhVjhVU2 , . J L N  " $ 8 : < F H J f h j ~ $(*>ھھھھھjJhV>*UjhV>*Uj^hV>*UjhV>*UjhV>*UmHnHujvhV>*UjhV>*U hV>*jhVUjhVUhV6>@BLNPlnp  jl =>LշժѢїѢьѢсѢj hVUj hVUj hVUjhVUj" hV>*UjhV>*Uj6hV>*UhV hV>*jhV>*UmHnHujhV>*UjhV>*U2LMNwx  8:<JLh謢{j&hVUjhV>*UmHnHuj hV>*UjhV>*U hV>*j: hVUj hVUjP hVUj hVUjh hVUhVjhVUj hVU,Pnr:6H7L777>8 (@@$a$gdr&] 3&]gdr&] (@ (@dh x (#(@@@@@@  $ xP (#(@@@@@@@@@ $ P(#(@@@@@hjlz|"$@BDVXtvx$&(<Ͷç{jhVUj`hVUjhVUjthVUjhV>*UmHnHujhV>*UjhV>*U hV>*jhVUjhVUhVjhVUjhVU-<>@JLPZ\xz| :<>PRThjlvxzѾձѦՙюՁjhV>*UjhVUj$hV>*UjhVUj8hV>*UjhVUjhVUhV hV>*jhV>*UmHnHujhV>*UjLhV>*U2  68:NPR\^`z|~ٽٽٽٽٽjhV>*Uj^hV>*UjhV>*UjrhV>*UjhV>*UmHnHujhV>*UjhV>*U hV>*hVjhVUjhVU3(*,BDFZ\^hjn  &(*46:շժ՝Ս}sh6CJOJQJh4"ThV5CJOJQJaJh4"Th65CJOJQJaJj"hV>*UjhV>*Uj6hV>*UjhV>*UhV hV>*jhV>*UmHnHujhV>*UjJhV>*U)$'+-./0:;6 6 666 7H7L7777òÞuo_SIhVCJOJQJh4"ThV5OJQJhr&]589>*CJ OJQJ hVCJhV>*CJOJQJ hV>*,jhV5>*CJOJQJUmHnHuU'jhV5>*CJOJQJU!jhV5>*CJOJQJUhV5>*CJOJQJ hV5CJhV5CJOJQJ hV5hVhV5CJOJQJhVCJOJQJ      (Injured member sign in ink) REPORT OF CHIEF OR SHERIFF Name of chief or sheriff  FORMTEXT       Officer in charge  FORMTEXT       How can such injuries be prevented?  FORMTEXT       Did member lose time from regular work? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Hospitalized? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Date of accident  FORMTEXT       Time of accident  FORMTEXT       Location of accident  FORMTEXT       Has the injured been registered as required by the Volunteer Firefighters & Reserve Officers Relief Act? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Did the injury occur as a result of a mobilization? Yes  FORMCHECKBOX  No  FORMCHECKBOX  X____________________________________ X_____________________________________ (Signature of Chief or Sheriff) (Signature of officer in charge) REPORT OF PHYSICIAN Date physician called  FORMTEXT       Time physician called  FORMTEXT       Describe in full the extent of injury  FORMTEXT       Estimate time loss, if any  FORMTEXT       X ______________________________________ (Signature of attending physician) REPORT OF LOCAL BOARD OF TRUSTEES Date claim filed  FORMTEXT       Date of hearing by local board  FORMTEXT       Date claim granted  FORMTEXT       Date claim rejected  FORMTEXT       X ___________________________________ X ______________________________________ (Chair of local board) (Secretary of Local Board) Please keep a copy of this form for your records and send the original to BVFF, PO Box 114, Olympia, WA 98507.  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