CTMD Form 1-12 "Injury Reporting Procedures" - Connecticut

What Is CTMD Form 1-12?

This is a legal form that was released by the Connecticut Military Department - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2013;
  • The latest edition provided by the Connecticut Military Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of CTMD Form 1-12 by clicking the link below or browse more documents and templates provided by the Connecticut Military Department.

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Download CTMD Form 1-12 "Injury Reporting Procedures" - Connecticut

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CTMD Form 1-12
(Rev. 11/2013)
CONNECTICUT MILITARY DEPARTMENT
INJURY REPORTING PROCEDURES
1. The Connecticut Military Department (CTMD) requires strict attention to safety in all state military
operations. This policy applies to all members of the Armed Forces of the State of Connecticut while
performing state military duty. Members of the Armed Forces of the State of Connecticut who incur an
injury or illness while performing state military duty must ensure the proper documentation is processed in
a timely manner.
The responsibility of proper processing of injuries and illnesses is a shared
responsibility between the individual, the unit leadership and the CTMD full-time staff. Commanders are
primarily responsible for ensuring the proper completion of all paperwork and notifications in a timely
manner, but the affected individual must also be diligent in following up in order to ensure that the
required information, documentation and reports are submitted and processed.
2. The CTMD Workers Compensation Procedures outlines the reporting procedure when an injury or
illness occurs. It also outlines the forms that need to be completed in the event that there is a loss of time
from work.
This procedure is posted in unit locations, is maintained by the unit Adjutant, and is
accessible on the CTMD website at www.ct.gov/mil. Violations of this policy should be reported through
the chain of command and also to the CTMD Personnel Officer at (860) 548-3248.
3. The documents that need to be completed are:
DAS Form 207 (First Report of Injury)
o
DAS Form 207-1 (Incident Review Report)
o
WCC Form 1A (Filing Status Exemption)
o
DAS Form PER-WC 211 (Concurrent Employment & Third Party Liability)
o
DAS Form WC-715 (Request for Use of Accrued Leave with Workers’ Compensation)
o
DAS Form 208 (Physicians Workers’ Status Report)
o
4. Commanders are responsible for recording and facilitating an employee’s claim by:
Obtaining emergency medical care if needed
o
Completing the claim packet
o
Phoning the claim into TPA injury intake center at 1-800-828-2717
o
Forwarding the completed claim packet to the CTMD Personnel Office
o
Initiating a serious injury report (SIR) and conducting a safety investigation, as required
o
Taking corrective action to mitigate any hazard(s) that caused the injury
o
5. Each member of the Armed Forces of the State of Connecticut, to include the Governor’s Guards,
must read and acknowledge understanding of this policy. Leadership and Commandants must ensure
that each member’s personnel file contains a signed acknowledgement of this policy. Annual briefings
are encouraged to be given to all members.
MARK A. RUSSO
Brigadier General
Assistant Adjutant General
I HAVE READ AND UNDERSTAND THIS POLICY
Signature
Printed Name, Rank & Unit
Date
Page 1 of 1
CTMD Form 1-12
(Rev. 11/2013)
CONNECTICUT MILITARY DEPARTMENT
INJURY REPORTING PROCEDURES
1. The Connecticut Military Department (CTMD) requires strict attention to safety in all state military
operations. This policy applies to all members of the Armed Forces of the State of Connecticut while
performing state military duty. Members of the Armed Forces of the State of Connecticut who incur an
injury or illness while performing state military duty must ensure the proper documentation is processed in
a timely manner.
The responsibility of proper processing of injuries and illnesses is a shared
responsibility between the individual, the unit leadership and the CTMD full-time staff. Commanders are
primarily responsible for ensuring the proper completion of all paperwork and notifications in a timely
manner, but the affected individual must also be diligent in following up in order to ensure that the
required information, documentation and reports are submitted and processed.
2. The CTMD Workers Compensation Procedures outlines the reporting procedure when an injury or
illness occurs. It also outlines the forms that need to be completed in the event that there is a loss of time
from work.
This procedure is posted in unit locations, is maintained by the unit Adjutant, and is
accessible on the CTMD website at www.ct.gov/mil. Violations of this policy should be reported through
the chain of command and also to the CTMD Personnel Officer at (860) 548-3248.
3. The documents that need to be completed are:
DAS Form 207 (First Report of Injury)
o
DAS Form 207-1 (Incident Review Report)
o
WCC Form 1A (Filing Status Exemption)
o
DAS Form PER-WC 211 (Concurrent Employment & Third Party Liability)
o
DAS Form WC-715 (Request for Use of Accrued Leave with Workers’ Compensation)
o
DAS Form 208 (Physicians Workers’ Status Report)
o
4. Commanders are responsible for recording and facilitating an employee’s claim by:
Obtaining emergency medical care if needed
o
Completing the claim packet
o
Phoning the claim into TPA injury intake center at 1-800-828-2717
o
Forwarding the completed claim packet to the CTMD Personnel Office
o
Initiating a serious injury report (SIR) and conducting a safety investigation, as required
o
Taking corrective action to mitigate any hazard(s) that caused the injury
o
5. Each member of the Armed Forces of the State of Connecticut, to include the Governor’s Guards,
must read and acknowledge understanding of this policy. Leadership and Commandants must ensure
that each member’s personnel file contains a signed acknowledgement of this policy. Annual briefings
are encouraged to be given to all members.
MARK A. RUSSO
Brigadier General
Assistant Adjutant General
I HAVE READ AND UNDERSTAND THIS POLICY
Signature
Printed Name, Rank & Unit
Date
Page 1 of 1