Attachment C: Injury/Illness Log INJURY, ILLNESS & AGENCY PROVIDED MEDICAL CARE (APMC) TREATMENT LOG INCIDENT NAME: Mountain Fire INCIDENT#: ID-BOF-000001 FIRE CODE: XX1A DATES: 06/30 07/09/15 – Forms Prepared Report Illness/Injury Nature of M#* Home Unit Name & Address Treatment CA-1 CA-2 CA-16 Disposition/ Remarks Date Date Injury/Illness Other Hot Shots, Boise NF Transported to CA-1 and 16 entered into 1249 S. Vinnell Way, Suite 200 1” laceration to clinic, 3 stitches, eSafety. Contact made with X X 07/04/14 07/03/14 Boise, ID 83709 right knee tetanus shot and ASC. Need follow up to antibiotic Rx remove stiches in 5-7 days. 208-373-4100 Payette Regulars, Payette NF Light duty for 24 hours. Camp crud with Transported to 800 W. Lakeside Ave. X Clinic visit and Rx paid with M-1 07/06/14 07/06/14 fever, sore throat clinic, cough APMC McCall, ID 83638 APMC by Buying Team and cough syrup RX member, Jan Doe on CC. 208-634-0700 Twin Falls District BLM All forms completed and CA-35 Stomach cramps, Transported to 2536 Kimberly Road faxed to home unit. Clinic X 07/07/14 07/07/14 & nausea and clinic, IV fluids Twin Falls, ID. 83301 visit and Rx paid by vomiting and 2 Rx given CA-20 employee. Demobed home. 208- 736-2350 *M#s are only issued for APMC payments and not OWCP
Attachment C: Injury/Illness Log INJURY, ILLNESS & AGENCY PROVIDED MEDICAL CARE (APMC) TREATMENT LOG INCIDENT NAME: Mountain Fire INCIDENT#: ID-BOF-000001 FIRE CODE: XX1A DATES: 06/30 – 07/09/15 Forms Prepared M#* Report Date Illness/Injury Date Home Unit Name & Address Nature of Injury/Illness Treatment CA-1 CA-2 CA-16 Disposition/ Remarks 07/04/14 07/03/14 Hot Shots, Boise NF 1249 S. Vinnell Way, Suite 200 Boise, ID 83709 208-373-4100 1” laceration to right knee Transported to clinic, 3 stitches, tetanus shot and antibiotic Rx X X CA-1 and 16 entered into eSafety. Contact made with ASC. Need follow up to remove stiches in 5-7 days. M-1 07/06/14 07/06/14 Payette Regulars, Payette NF 800 W. Lakeside Ave. McCall, ID 83638 208-634-0700 Camp crud with fever, sore throat and cough Transported to clinic, cough syrup RX X APMC Light duty for 24 hours. Clinic visit and Rx paid with APMC by Buying Team member, Jan Doe on CC. 07/07/14 07/07/14 Twin Falls District BLM 2536 Kimberly Road Twin Falls, ID. 83301 208- 736-2350 Stomach cramps, nausea and vomiting Transported to clinic, IV fluids and 2 Rx given X CA-35 & CA-20 All forms completed and faxed to home unit. Clinic visit and Rx paid by employee. Demobed home. *M#s are only issued for APMC payments and not OWCP Other
NorthernRockiesOWCPGuide_2015Accessible.docx