Forms Flashcards
1
Q
F-HMIF, PB-8
A
Hazardous Materials Form Direction
- Copies: 1
- Retained: 3 years
- Forward: Data Management Unit, Technical Section, FPB
2
Q
Notice to Comply Form SD
A
Smoke Detector
- Copies: 4
- Retain: 3 years
- Enforcement: Building and Safety and LAFD
- Required: Occupancies containing 2 or more dwelling units
3
Q
DWC Form 1
A
Claim Form
- Work Related injury/illness, Law requires employer to provide within 24 hrs of occurrence to injured member
- Copies: 5
- Retained: Indefinitely by members
- Forward: When member received treatment
- Document: F-2 when forwarding
4
Q
F-2
A
Journal (Record of daily History)
- Retain: 1 year after the last entry
- Forward: To Manuals and Orders (Mail Stop 250)
- Identification: Inside front cover, station #, start date
- Red Ink: Date, Alarm, Emergency/Non-Emergency Move up as result of Alarm
- Green Ink: Pay roll Symbols
- Blue/Black Ink: All other entries
5
Q
F-3
A
Hazardous Substance Exposure Report
- Copies: 2 (1) member, (1) MLU
- Forward: Medical Liaison Unit immediately following exposure
6
Q
F-5
A
Daily Staffing Roster
- Copies: 1
- Retain: 90 days after calendar year
- BC Aid shall call stations prior to 2100 hours to ensure 5 day staffing
7
Q
F-8
A
Roster Change
- Used to notify Personnel Services
- Copies: Print 1 for Civilians, 2 Uniformed members, 3 copies for Chief Officers
- Forward: 24 hours after any changes, through channels to Personnel Services
- Exception to Forwarding: Verbal notification by on duty Station Commander
- Changes: Underline in RED ink, but do not abbreviate
- Changes include: Residence, Phone #, Marital or Domestic Partner, legal name changes
8
Q
F-9
A
Roster Card
- Roster retained at Battalion and Division
- Copy: 1
- Retain: Until separation from department
- Forward: Time of Transfer
- Routing: New Battalion and Division if applicable
9
Q
F-10
A
Medical Exam Record
- 3”x5” preprinted card
- Copy: 1
- Retain: Until separation from department
- Forward: Time of transfer
- Routing: New Battalion and Division if applicable
10
Q
F-11
A
Station Daily Roster
- Use the same symbols used in the F-5054s
- Retain: Discard after usefulness has passed
11
Q
F-13
A
On/Off Duty Checklist
- Used to assure that all notifications and documentation is completed when a member either goes off duty or returns to duty
- Copies: 1
- Retain: Until Usefulness has passed
12
Q
F-16
A
Vehicle Shop Numbers and Lock Box Assignment
- Completed at the end of each quarter
- Copies: 2
- Retain: 1 year
- Forward: No later than 5th day following quarter
13
Q
F-17
A
Pay Grade Advancement Application for Premium Hazard Pay
- Copies: 1
- Retain: 1 year
- Routing: In January, forward to Personnel Services
14
Q
F-18
A
Transfer of Uniform Personnel
- Used to notify City’s Controller of change of work location/payroll
- Copies: 1
- Retained: Personnel Services Indefinitely
- Routing: Through channels to Members Bureau Commander
15
Q
F-18A
A
Request for Transfer
- Used for member to declare a desire for assignment
- Copies: 2
- Retained: End of Calendar year
- Routing: Original to Bureau, Duplicate back to member
16
Q
F-18B
A
Request for Transfer Primary Vacancies
- Used for member to declare a desire for assignment
- Copies: 2
- Retained: End of Calendar year
- Routing: Original to Bureau, Duplicate back to member
17
Q
F-20A
A
Evacuation Notice (English)
- Used during evacuations
- Copies: 1 per household
18
Q
F-20B
A
Evacuation Notice (Spanish)
- Used during evacuations
- Copies: 1 per household
19
Q
F-23
A
Emergency Overtime Report
- To apply for approval of 1 1/2 time in emergency hours worked, in 1/10 hour increments
- Copies: 3 (1) Bureau, (1) Accounting, (1) Station File
- Forward: Forward with 5054 no later than end of week in which overtime worked
- Routing: Account Services
- Retain: 2 years
- Includes: EOD and Court Time
20
Q
F-26
A
Report of Administrative Overtime (AOD)
- Used to request AOD Overtime, while working voluntary OT at emergencies
- Copies: 3
- Retained: Original (Accounting Services)
- Retained: Duplicate, returned through channels to member
- Retained: Triplicate, with member until duplicate returned
21
Q
F-41
A
Revision Report
- Used to recommend revision in the Manuals, Notify Planning
- Copies: 1
- Retain: Until Manual and Orders takes action
- Separate F-41 per recommendation
22
Q
F-44
A
Intra-Departmental Memo
- Used by FPB or Field Officers for written communication between them
- Copies: 3
- Retain: 3 years
- Limit: Limited to 1 occupancy per F-44
23
Q
DL 44C
A
Application for Commercial Drivers License
- Copies: 1
- Forward: To DMV with Forms DL-51 and DL-51A
24
Q
F-49
A
Ordinance Leave
- Immediate Family due to illness/injury, Death and Preventative Medical
- Copies: 2
- Routing: Original to Accounting Services
- Forward: Upon return to duty
- Requested Hours: Enter to the nearest whole number
25
F-63
Fire Prevention Summary
- Copies: 2 by each shift commander
- Forward: Last working shift of the quarter no later than 5th day of following quarter
- Retain: 5 years in Station files
- City of San Fernando: Forward separate F-63 for Fire Prevention conducted in San Fernando
26
F-63A
Fire Prevention Activities
- Copies: 1
- Retain: 3 years in Book #55
27
F-63B
Daily Training and Fire Prevention Activities
- Copies: 1
- Retain: 3 years in Book #55
- Record hours to the nearest 1/4 hour
28
FG-68
Military Leave Compensation
29
F-70
Hydrant TEST Record
- Used by companies to record hydrant testing. To cover 5 hydrant tests per sheet
- Copies: 1
- Retain: In Hydrant Book, when completed put 1 year in file
30
F-79
Notice of Commendation
- Any supervisor in Chain of Command may complete
- Copies: 3
- Routing: Original returned to member AFTER Bureau approval
- Routing: Duplicate to Personnel Services
- Routing: Triplicate to Department of Personnel (City)
31
F-80
Store Requisition
- Copies: 3
- Retain: 3 months at assignment
- Retain: 3 years for Medical Supplies**
- Forward: 2 copies to the concerned Department.
- Maintain 1 copy in members/stations folder
32
Form General 84B
Witness Card
- Completed by NON- city employee who witnesses onscene of accident
- Copies: 1
- Retain: Permanently
- Forward: with FG-88 (Accident Report)
33
F-85
Request for Legal Ownership
- Used to determine owner of property when siting FP violations
- Copies: 2 (1) Legal and (1) Station file with F-173 (Occupancy Record)
- Retained: 5 years
- Forward: Legal Liaison, FPB
34
Form General 88
Accident Report
- Prepared when accident causes damage to property or bodily injury
- Copies: 5
- Retain: Permanently
- Forward: Within 24 hours to Bureau through channels then forwarded to Personnel Services
35
F-95
Fire Hydrant RECORD
- To keep record of fire hydrants, 1 hydrant per line*
- Copies: 2 (1) Hydrant Book and (1) FPB
- Retain: Permanently
- Forward: When new pages are required by FPB Hydrant Unit
36
F-100
Suggestion Form
- To suggest new methods or procedures
- Copies: 1
- Retain: 5 years in Planning Section
37
F-101
Emergency Activity Report- Personnel
- Used to document use of Personnel and Equipment at all MAJOR Incidents (Earthquake, Floods, Civil Disturbance)
- Copies: 2
- Routing: Management Services Section and retain duplicate in Station File
38
F-101
Emergency Activity Report W/ Multiple
- Multiple F-101s
- Used to document responses at Major Emergencies
- Copies: 2
- Routing: Management Services, duplicate Station file
39
F-113
Analysis of Emergency Operations
- Used on all Major Emergencies or as directed
- Copies: 3 (1) ESB, (1) FPB, (1) Training
- Routing: Through channels to Bureau
40
Form General 113
Request Station Repair/Maintenance
- Detailed information on request of repairs/maintenance
- Copies: 2
- Routing: Building Administration
- Entries: Type all entries
- Retain: Until usefulness has passed
41
F-121
Hose Inventory Record
- To record date hose was issued
- Copy: 1
- Retain: Until usefulness has passed in Book #55
** Hose expected life is 10 years (*AOTM states: 5 years)
42
F-122
Hose and Salvage Cover Overlay
- Copy: 1
- Retain: Book #55
- Used: Use in conjunction with F-128 (Hose/Salvage Cover Record)
- Use both sides of Form (Hose section numbers and salvage cover numbers)
43
F-126
Bed and Locker Assignment Record
- Copy: 1
- Retain: Book #55
44
F-128
Hose and Salvage Cover Record
- Kept in Book #55
- Copies: 1
- Retain: 6 months
- Used: Using in conjunction with F-122 (Hose and Salvage Cover Overlay)
45
F-129
Annual Hose Test Record
- Copies: 2
- Routing: 1 copy to Equipment Engineering
- Retain: Book #55
- Sign: Only 1 officer signs
46
F-150
Accident Report- Investigating Officer
- Copies: 1
- Forward: After obtaining all reports (F-225, Form General 88, Form General 84)
- Routing: Bureau Commander
- Retain: 1 year at Personnel Services
47
F-151
Accident Report Procedures
- Retain: F-620 (Accident Packet)
- Used: As a procedural guide
48
F-161
Authorization for Delivery of Unpaid Salary Check
- Copy: 1
- Retain: Until Action completed or renewal filed
- Authorize Payroll to mail check after retirement or separation
- Paychecks not picked up by members by next assigned platoon duty shift with no F-161 on file- Commander return to payroll
49
F-165
Duty Certificate
- Used to report Return to Duty Status on all leaves when member was scheduled to be at work on duty
- Copies: 2 for NIOD, 3 copies for IOD (1 copy civilian)
- Medical Treatment: When F-1001 is required, staple F-165 and forward both
- Use: For IOD and NIOD
- Additional Leave use: Military, Civil Service, Disciplinary, Special
50
F-166A
IOD Illness or Injury Report
* Discontinued
- Replaced by F-5020
51
F-166B
NIOD Report
- Any NIOD illness/injury, includes SOD shift which is working responsibility
- Copies: 2
- Forward: 1 copy within 24 hours
- Routing: Medical Liaison Unit
- No Code-A-Phone required when going off duty
- Time Documented: Use 24 hour clock
52
DL 170
Certificate of Driving
- For original issue of Class "B" or "A" license, or change "B" to "A"
- Used if current license expires more than 6 months ago
+ For Original Passenger Endorsement:
- Copies: 2
- Orignal Copy: DMV
- Routing: In service training through channels
- Driving Courses: FS 3, FS 40, and FS 88
53
F-173
Occupancy Record
- Used to indicate General Occupancies
- Copy: 1
- Retain: 3 years
54
F-173A
- Occupancy Record, FPB
- Used to indicate FPB Occupancies
- Copy: 1
- Retain: 3 years
55
F-175 Tag
Material to Storeroom Tag
- Attach to article
- Print Legibly
56
F-211
Citation
- The act of a misdemeanor must be witnessed by the person issuing the citation. List specific code section violated and print a short description of offense.
- Instructions: Members shall conform to the instructions appearing on the INSIDE cover of the Citation Book
- Copies: 4
- Retain: 3 years
57
F-215
Equipment Loan Receipt
- Use when leaving equipment at the scene
- Copies: 2
- Retain: Until returned
58
F-215M
RESCUE Equipment Loan Receipt
- Use when lending Equipment at Medical Facilities
- Copies: 2
- Retain: 72 hours MAX, or when equipment is returned
- Forward: With F-225 through channels when equipment is LOST
59
F-223
Intra-Departmental Correspondence Red Letterhead WITHOUT Boxes
- Used when a formal report is needed and no other form is provided, and when routing through channels is NOT desired
- * Volume 5 has form down as F-233 (typo)
- Retain: 1 year or until usefulness has passed
- Through Channels: Addressed to the highest office
- Sign: Signed by the originator on the last page
- Font: Aerial 12, may use 11 to conserve space
- Margin: 1"
+Format
- Date:
- To:
- From:
- Subject: All Capitals with ATRS# (Assignment Tracking Report System #)
- Summary
- Recommendation
- Findings
- Conclusion
60
F-225
Intra-Departmental Correspondence Red Letterhead WITH Boxes
- Used when a formal report is needed and no other form is provided
- Retain: 1 year or until usefulness has passed
- Through Channels: Addressed to the highest office
- Sign: Signed by the originator on the last page
- Font: Aerial 12, may use 11 to conserve space
- Side Margin: 1"
+ Format
- Date:
- To: When going through channels use Capitals
- From:
- Subject: All capitals with ATRS# (Assignment Tracking Report System #)
- Summary
- Recommendation
- Findings
- Conclusion
61
F-226A
Informal Grievance Discussion
- Initiated by Immediate Supervisor, to document informal discussion
- Copies: 1
- Forward: ASAP
- Routing: Department Management Representative, through channels
- Delivery: Officer personally delivers without delay, through channels and filed in the grievance file
- Note: Member has 15 calendar days to file FORMAL Grievance.
62
F-226B
Formal Grievance
- Initiated by Grievance to request review of a grievance at all formal levels
- Copies: 5
- Forward: Within 10 calendar days from the date (*MOU says 15 days)
- Routing: 4 copies to Department Management Representatives
63
F-226C
Reply to Statement of Grievance
- Initiated by the Grievance reviewer to reply to an F-226B (Formal Grievance)
- Copies: 5
- Forward: Within 15 days (NOT calendar days like for "A" and "B") from the time the F-226B was received in Battalion. Form will be time stamped by Department Representative
- Delivery: Hand delivered in person or by Registered mail
- Fire Commission Review: 21 days
64
F-228
Fire Department BLACK Letter Head
- Correspondence to Government Agencies, Organizations, Businesses and the General public for letters of appreciation
- Sign: Signed by the originator on the last page
- Font: Aerial 12, may use 11 to conserve space
- Side Margin: 1"
- Closing: "Sincerely" is used
- Signature Boxes: Fire Chief, but originator signs
65
F-250
Weekly Bulletin
- Initiated by the Fire Chief. Announcement published 1 time, twice for class reunions or retirement dinners
- Retain: 1 year
- Size: 8 1/2" x 11"
* One of three parts in library that supersede MOPS: BNR-Weekly Bulletins, Special Notices, Rules and Regs
66
F-280
Division 5 Permit
- Copy: 1
- Forward: To FPB Environmental Unit
- Retain: Indefinately
67
F-290
Request for Legal Action
- Used to summarize information needed for prosecution of a case
- Copy: 2
- Retain: 5 years
- Routing: Legal Liason
68
F-295
Hazardous Material Shipping Paper
- Copy: 1
- Remain: With transport apparatus
69
F-315
Special Permit
- Issued for open outdoor fires
- Copies: 3
- Expiration: No longer than 1 year or usefulness has passed
70
F-334
Complaint of Hazard
- To record Citizen Complaints
- Copies: 1
- Filed: File in Complaint Book
- Retain: As long as of value
- Council Complaints: RED ink
+ F-334 Posting
- Other than Mountain Fire District: Issue F-340A (Fire Life Safety Violation). Document posting of F-335A (Notice to Abate Public Nuisance and Fire Hazard) on back of F-340A with signature and date.
- Mountain Fire Districts, Fire Buffer Zones, Mt. Washington: Post F-1308A (Notice of Non-Compliance) 4th copy
71
F-335A
Notice to Abate Public Nuisance and Fire Hazard
- Used to notify owners of property of violation
- Copy: 1 in a conspicuous location on premises
+ Posting
- Other than Mountain Fire District: Issue F-340A (Fire Life Safety Violation). Document posting one F-335A on back of F-340A with signature and date
- Mountain Fire Districts, Fire Buffer Zones, Mt. Washington: Post F-1308A (Notice of Non-Compliance) 4th copy
72
F-336
Condemnation Tag (RED Tag)
- Used in condemning appliances or Equipment pursuant to the authority of the Chief
- Copy: 1
- Posting: Attach to appliance or device
- Use: Ink
73
F-337
Notice of Re-Inspection
- Used by Fire Companies
- Routing: Left at scene of re-inspection or at scene of an incident
74
F-338
Interdepartmental Referral (PINK)
- Used to direct violations of LA Municipal Code to Responsible Department
- Copies: 2, type or clearly print
- Retain: 3 years
- Routing: Original Pink to Department
- YELLOW duplicate into pending file
- Vacant Structures: Unsecured structures, forward with F-340A (Fire Life Safety Violation)
- Lot Cleaning: Mail Stop 550
- Nuisance Abatement: Mail 115 (Building and Safety)
75
F-339
Posting Hazardous Building
- Used with Notice to serve as warning of Fire, Explosion or Hazard
- Copy: 1
- Routing: On exterior of Premise
76
F-340, A,B,C,E,FW
Fire Life Safety Violation
- Copies: 340A and B (3 copies), 340 C and E (2 copies)
- Retain: 3 years
- Vacant Lots: Do NOT issue on Vacant lots
- Re-inspect: Shall NOT be over 30 days of issue
- Routing: Citizens. If Municipally, forward to Legal Liaison
- Legal Action: Note of F-173 (Occupancy Record)
- Major Progress Extension: 15 additional days may be granted
* A: General Fire Life Safety
* B: Exits/Blocked Door/Signs
* C: Blank
* E: Overcrowding
* FW: Fire Watch
77
F-340D
Fire Protection Performance Certification
- Used to inform owner of required testing, maintenance and repair
- Copies: 4
- Retain: 5 years
- Routing: 1st, 2nd, and 3rd to Owner, 4th in station file
- Test: Within 30 days
- Repairs and Retest: Within 30 days
78
F-341
Noncompliance Fee Form
- Utilized to initiate billing of a business or occupancy for re-inspections due to being non-compliant
- Copies: 2
- Retained: Legal Liaison for 3 years
- Retained Accounting: Permanently
79
F-351
Time Record
- Used to maintain an Annual Record of Vacations, Holidays, Trades, and FLSA
- Copy: 1
- Retain: In Book #55 until calendar year END
- Retain Copies: 3 years
- Forward: Accounting Section within 10 days of years END, or separation from Department
- 126 Day Cycle: Used when member transfers to new assignement
- 8-Hour Schedule: Member will use 1 full platoon duty day (12 hrs) for each 8 hr day taken off detail duty
- 9-Hour Schedule: Member will use 1 1/8 platoon duty day (13.5 hrs) for each day taken off detail duty
- 10-Hour Schedule: Members will use 1 1/4 platoon duty day (15 hrs) for each 10-day taken off detail duty
80
F-351A
Time Record Worksheet
- Used with F-351 (Time Record)
- Copy: 1
- Retain: In Book #55 until calendar year END
- Retain Copies: 3 years
- Forward: Accounting section within 10 days of years END, or separation from Department.
- Symbols: The same used on F-5054
- FLSA Hours: All time required to be on the employer's premises on duty or at a prescribed workplace. Actual court appearances, not for stand by hours. Traded time taken off is recorded in the shades boxes as FLSA hrs worked.
81
F-360
Adjustment of Platoon Duty (Trades)
- For exchange of maximum of 1 full shift
- Copies: 2
- Retain: End of calendar year
- Routing: To commander for approval, than in members file
- Approval: Upon approval, make entries in F-351
- Sign: Both members shall sign
82
F-361
Request Time Off or Vacation Time
- Copies: 1
- Retain: AOD and TS until end of PAY PERIOD
- Retain: Vacation and Holiday until end of calendar year
- Routing: Member's folder
- Thanksgiving, Christmas Eve and Christmas Day: At least 9 days but not more than 60 days prior to leave, HOLIDAY: within 5 days or less
- TS Trade: Underline Statement in RED Ink
83
F-366
Private Hydrant Report
- Used to notify Stations of private hydrant installation and type of system connected.
- Copies: 2 (1) Hydrant Unit and (1) Company
- File: File in Hydrant Test Book
84
F-367
Fire Hydrant Report
- Sent to stations when installed, enlarged, relocated or removed.
- Copies: 2 (1) Maps and Drafting and (1) Hydrant Unit
- Forward: To Hydrant Unit within 14 days of receipt
85
F-370
Record of Drivers Training
- To document individual drivers training activity for "A" and "B" License
- Copies: 2 (1) In- Service and (1) Personal folder at work location
- Retain: Indefinitely in member's folder and In-Service
86
F-377
Bi-Monthly Inspection
- To document preventative maintenance of apparatus
- Copies: 2
- Retain: Last 6 copies in Log Book
- Completed: Engineers, Apparatus Operators and responsible members
- Forward: 1 copy to BC within first 2 weeks of appropriate month. Copy to arrive no later than day before inspection or 15th
- Signature: Station Commander/Unit Commander initial
- F-80: Must forward F-80 with repairs along with F-377 to BC
* Heavy Apparatus (Front line/Relief): February, April, June, August, October, December (EVEN months)
* Light Apparatus (Front line/Relief): January, March, May, July, September, November (ODD months)
* Reserve Apparatus: Every 4 months
87
F-377 RA
Bi-Monthly Inspection Rescue
- Copies: 2
- Retain: Last 12 copies
88
F-380
Apparatus Yearly Mileage
- To record miles driven in Fiscal Year and total miles of vehicle
- Copies: 2
- Retain: 1 year
- Forward: S&M by 10 days after fiscal year
- Transfer: Last F-380 myst be forwarded with Logbook
89
F-392
Fuel Usage Report
- Reflects all Fuel consumed during pumping, Aerial and All off Highway miles
- Copies: 2
- Forward: Account Services, no later than 5 days after end of each MONTH.
90
F-393
Training Activity Record
- Copies: 1
- Retain: Indefinitely in Members Folder
- Haz Mat Entries: In GREEN ink
91
F-398
Weekly Crew Time Sheet (Correction)
- Used to make changes on Weekly Time Sheets (5054s)
- Copies: 2
- Forward: Both copies to Account Services Section
- Return: Returned from Accounting, put in personal folder
- Approve: Supervisor, Members shall not approve own timekeeping
92
F-398A
FLSA Crew Time Sheet (Correction)
- Copies: 2
- Forward: Both copies to Account Services Section
- Return: Returned from accounting into personal folder
93
F-398C
FLSA after 40 Crew Time Sheet (Correction)
- Copies: 2
- Forward: Both copies to Account Services Section
- Return: Returned from accounting to personal folder
94
F-400
Community Directory
- Copy: 1
- Retain: Book #20 Public Affairs
95
F-420
Communicable Disease Exposure and Notification Report
- Notifies staff at Receiving Facilities, LAFD may have been exposed
- Copies: 3
- Forward: Original Medical Facility, 2nd Medical Liaison Unit Immediately, 3rd Employee
- Completed: By member at the time of exposure
- Confidential: Only release to those persons directly involved in follow up care
96
F-526
Duplicating Services (Making Copies)
- Copy: 1
- Retained: Manual and Orders until usefulness
97
F-527
Occupant Load Sign
- To request Occupant Sign from Maps and Drafting
- Copy: 2
- Sign numbers and letters NOT less than 1/2" in height
98
F-579
Correction Needed to F-580 (Overtime Report)
- Initiated by: Station Commander
- Copies: 2 (2) Accounting Services, (1) copy returned after correction made
- Routing: Account Services
99
F-580
Overtime Report
- Record of members accumulated overtime
- Summarized: Report send to station every 6 months
- Copies: 2 (1) Accounting and (1) Company Headquarters
- Retain: Last 2 summaries
100
F-590
Record of Overtime Card
- Used to keep record of all numbers charged when a member works overtime
- Copy: 1 per member
- Retain: 90 days
- Complete: Each time member works overtime
- NOTE: Volume 5, F-590 instructions include details for the hiring of Overtime
101
F-591
Station SOD Request Record
- Used to keep record of members request to participate in working SOD
- Retain: 90 days
102
F-592
SOD Notification
- Used as a reminder, members scheduled to work SOD
- Retain: Until usefulness has passed
103
F-620
Accident Packet
- Retain: Permanently in Department Vehicles and 2 spares in station
- Forms in Packet: Form General 84B, Form General 88, F-150, F-151
104
F-665
Large Scale Emergency Package
- Carried on ALL emergency vehicles
- ICS breakdown
- Worksheets
105
F-666
Resource and Situation Status Record
+ Two-Sided Form:
1. Multi-story/High Rise/Ship Incident
2. Brush or 1 story incidents
- Retain: Place of origin
- ENR Column: Best to split (list) TF separately as "E" and "T"
106
F-666A and B
Resource and Situation Status Record
- Normally used by DIVISION Commanders
+ Two Sided Form
1. F-666A Multi Story
2. F-666B Single Level Incidents
- Marking: Can use a check mark, an X or the time as appropriate
107
F-666C
Hazard Material Incident Data Sheet
- Forward: With F-902 and F-113 as needed
- Routing: Through channels to Research Unit with F-902 and F-113
- 7 Page Report: 7 page check off package is provided in each Haz Mat unit
- Mobile Labs: Carries 12 copies
- Ordering: Manual and Orders
108
F-666E
Multi-Patient Incident Worksheet
- Initiated by 1st on scene EMS or Fire Resources
- Carried: Carried on ALL Paramedic units and SOME Fire Units
109
F-666 S&T
Strike & Tactical Teams
- Form: Consist of 2 sheets
- F-666S: Tracking Formation and Deployment of Strike Teams
- F-666T: Tracking Formation and Deployment of Tactical Teams
110
F-673
Paramedic Worksheet
- Copies: 1
- Forward: ER with patient
- Records: times, dosages, and drugs administered
111
F-701
Statistical Information
- Retain: Log Book
- Copies: 2 (1) Logbook & (1) S&M
112
F-702
Assignment Record
- Retain: Log Book
- When transferred or detailed, OFFICER will check inventory
113
F-704
Maintenance Record
- To keep records of maintenance and Lube records
- Copies: 1
- Retain: Last 6 copies
114
F-705
Repair Record
- Retain: Log Book
- Retain: Permanently in Log Book
115
F-706
Battery Record
- Copies: 1
- Discard: When completely filled
116
F-709
Firefighting Inventory Record
- Retain: In Log Book
117
F-710
Tire Record
- Copies: 1
- Retain: Permanently in Log Book
118
F-725 to F-745
Found in PRB
119
F-725
Personnel Record Book Table of Contents
120
F-726
Personal Record
121
F-726A
Notification Record
122
F-727
Address-Phone
123
F-728
Evaluation
124
F-729
Assignments
125
F-730
Details
126
F-731
Driver License
127
F-732
Training
128
F-733
Medical Fitness & Immunization
129
F-734
Illness or Injury, Continued Duty Form
130
F-735
Leaves
131
F-736
Protective Equipment Record
132
F-737
Education, Colleges
133
F-741
Probationary Record Chart- Orientation
134
F-743
Medical Training Record Probationary
135
F-745
Hazardous Substance/Communicable Disease Exposure Record
136
F-863
Barbecue Permit
- Copy: 2
- Retain: 1 month after expiration of F-315 (Special Permit)
- Issued: Person concerned attached to F-315
- F-315: Issued to schools, churches, day nurseries
137
F-902
Field Incident Report
- Copy: 1
- Retain: 5 years by ARSON
- Reference: Field Incident Code Book
- Routing: Information System Unit
138
F-902M
Medical Report
- Copy: 4
- Retain: 10 to 20 years by the Department
- Forward: Per EMS Instructions (Book#5)
139
F-903
Controlled Medication Inventory Record
- Initiated by Paramedics and EMS Captains
- Copies: 1
- Retain: 3 years
- Reference: Book #33 (Pre-hospital Care Policy Handbook) and Reference 702 and 717
+ Shall be completed:
1. Shift Change
2. Personnel Change
2. Inventory Change
140
F-904
Situation Report
- For inquiries and feedback: Will assist Department with incidents, policies, practices and procedures. Identify system trends
- Copies: 3, type or print
- Retain: 1 year
- Routing: Through channels to EMS Captain by END of shift
- Routing Duplicate: Quality Improvement Section (QIS)
- Tablet Format: Available at S&M
141
F-916A & F-916B
Request Photo Services & Audio Duplicate
- No forms are required when request services, just PHONE
- Copies: 3 needed for Photographer
- Routing: Original to Photo Video
142
F-955
Information Pamphlet "What to do after a Fire."
- Issued to owner or post in building
* 1 per dwelling unit
* Adequate supplies of these forms are to be carried on ALL Fire companies and Chief officer's sedans
* Causes and origin of the fire may be discussed UNLESS it is:
1. Incendiary
2. Suspicious
3. Under investigation
4. Involves Juveniles
5. Fatalities
6. Serious Burns
* In the cases listed above, questions about cause should be referred to Arson Investigation Section.
143
F-957
Company Activity Schedule
- Monthly schedule of activities, by Platoon
- Copies: 2 (1) Station & (1) Battalion
- Retain: Duplicate 1 year
- Routing: To BC at least 5 days prior to start of month
- Fire Prevention "Re-Inspection": Note on F-957
144
F-971
Community Relation Activity Report
- Used when a Group, Church, Boy Scout or School visits Fire Station
- Copies: 1
- Retain: 1 year by DIVISION
- Neighbor Visit: NO need to report for neighborly visits
145
F-972
Daily Pre-Trip Inspection Record
- Used by members responsible for Heavy apparatus checks
- Copies: 1
- Retain: 1 month after last entry in Log Book
146
F-973M & F-973W
Apparatus/Equipment Check Record
- Weekly and Monthly Check Record
- Copies: 1
- Retain: 1 month after last entry, in Book #55
147
F-974
Reserve Apparatus Condition and Inventory Record
- Copies: 1
- Retain: Log Book 1 year from last entry
148
F-975
Lifeline/Rescue Kit
- Document the date of issue, usage, and monthly inspection of kit
- Enter: 1 operation PER line
- Retain in Book #55
149
F-976
Annual Ground Ladder Inspection Record
- Copies: 1
- Retained: In Log Book
- Forward: To S&M when ladder is removed from service
150
F-977
Apparatus Inspection Checklist
- Used by Company Commander and BC to document Bi-Monthly inspection of apparatus.
- Copies: 1
- Retained: 3 years in Log Book
- Signature: BC and company commander
151
F-978A
Heavy Apparatus Undercarriage Inspection CHECKLIST
- Used by Company Commander and Battalion Commanders to document 4 month inspection of apparatus undercarriage
- Copies: 1
- Retain: 3 years in Log Book
- Signature: BC and Company Commander
152
F-978B
Heavy Apparatus Undercarriage Inspection RECORD
- Used by BC to document 4 month inspection of apparatus undercarriage
- Copies: 2, (1) to S&M, (1) Log Book
- Retain: Per F-978 form 1 year in Log Book (*Volume 5 states: 3 years)
- Only BC Signs
153
F-979
SCBA Inspection Checklist
- Used by Company commanders and BC to document the Bi-MONTHLY inspection of SCBAs
- Copies: 1
- Retain: 3 years in Book #55
- Signature: BC and Company Commander
154
F-1000
Work Compensation, IOD, Dr. Recommendations Status, 1st Care Follow Up
- To provide Dr with checklist of Duty Status Recommendations
- Copies: 1
- Retain: MLU Indefinitely
- Forward: To MLU immediately following IOD Dr. appointment
155
F-1001
Dr. Work Status, Limitation Notification Report
- Used to establish proof of illness or disability
- Copy: 1
- Forward: MLU
- Retain: Indefinitely
156
F-1104
Notice to Improve
+Deficiency observed In:
1. Appearance
2. Attitude
3. Work Habits
4. Performance
5. Actions
- Any supervisor within member's chain of command with direct knowledge may issue to secure correction of deficiency.
- Copies: 3
- Retain: Until deficiency corrected or permanently
- Routing: 1 to member, 1 to officer, members Bureau Commander
+ Signature:
1. Member must sign copies but signature does not denote concurrence, or non-concurrence
2. If member refuses to sign the document, the issuing supervisor shall sign the document in member's presence (with date and time) documenting the member's refusal
- Check box: Check either, "concur" or "Do not concur"
+ Deficiency CORRECTED
1. When corrected, and in no case longer than 6 months from the date of issue, the member's immediate supervisor shall indicate so on both the FIRST and SECOND copy.
2. Member's immediate supervisor shall forward the SECOND copy through channels to the member's Bureau Commander.
3. Once Bureau receives the SECOND copy, the member's Bureau Commander shall return SECOND and THIRD copies to member.
+ Deficiency NOT Corrected
1. Additional notices may be used
2. Supervisor may enter in the Complaint Tracking System (CTS) however, the notices themselves shall NOT be attached to the complaint.
157
F-1105
Reprimand
- Used in cases of Serious or repeated violations that necessitate appropriate action and proper documentation.
+ Investigation:
1. All reprimands shall be written by PSD IF, after a complete investigation, including any mitigation factors, PSD determines that a Reprimand is the most appropriate course of action.
2. PSD will email Reprimand to the member's Bureau Commander for forwarding through channels to member's immediate supervisor.
- Initiated by: PSD
- Copies: 3 (1) member, (1) PSD, (1) Members Personnel Folder at Personnel Services Section
- Immediate supervisor signs all THREE copies and return 2 copies to immediate supervisor.
- Supervisor forwards to PSD without delay
- Employee Representative: Member may have a rep present during issuance
- Signature: member must sign and date and indicate concurrence or non-concurrence
- If member refuses to sign the document, the issuing supervisor shall sign the document in member's presence (with date and time), documenting member's refusal to sign.
+ Non-Concurrence
1. Per FF Bill of Rights, a member may request an administrative appeal (Grievance) challenging the Reprimand.
2. The 15 day calendar day period (Step 1) of Grievance begins on day FOLLOWING the day Reprimand was presented to member.
3. During the period of time in which the appeal is proceeding through the Grievance procedure, the 2 originals of the Reprimand shall be retained by PSD.
4. If the appeal is APPROVED, the 2 originals shall be returned to the member.
5. If the members' appeal is DENIED, the member shall have 30 calendar days to file a written response to the Reprimand. The written response shall be attached to, and shall accompany, the Reprimand into the member's personnel file.
- Retain: permanently in member's folder at Personnel services
- Routing: (1) member, (1) officer, (1) PSD then forwarded to Personnel Services
158
F-1109A
Visitor Waiver
- Sign prior to use of facility or equipment
- Copies: 2 (1) Visitor, (1) to BC to Public Service Unit
- Retain: 1 year
- Forward: BC then to Public Service Unit
159
F-1109B
Indemnity Agreement
- Used before visitor uses Facility/Equipment NOT employed by City that may cause injury
- Copies: 2 (1) Visitor, (1) BC then to Public Service Unit
- Retain: 1 year
- Forward: BC then to Public Service Unit
160
F-1109C
News Release Endorsement
- Prepared by Office before releasing material or equipment
- Copies: 2 (1) Applicant, (1) Public Service Unit
- Forward: Administrative Office to Public Services
161
F-1117
Notice of Promotion Notice
- Copies: 2 (1) member promoted, (1) Headquarters personnel folder
162
F-1122
Performance Evaluation
- To record Employee Performance of Duties
- Copies: 1
- Retain: Permanently
- Routing: Personnel Services Section
- Copy: Given to employee at the time of Evaluation
- Non-Concurrence: Member has 30 days
- Unsat: Rater F-225 to Bureau Commander attached to F-1122
163
F-1132
Officer Evaluation
- Officer evaluation
- Same as F-1122
164
F-1142*** NOTE
Probationary Firefighter Evaluation Forms
- ***All F-1142 forms in Volume 5 are incorrect per current department policy but this is wha the portal states as of June 10, 2017.
165
F-1142
Probationary Firefighter 10 Shift Evaluation
- Copies: 4
- Retain: Original, permanently at Personnel
- Retain: 5 years at Recruit Training
- Routing: Originals at Batt unil 10 MONTH, than Personnel, through channels.
- Below Standard: Must have specific comment made in comment section
- Over All employee rating: Unsatisfactory, must make comment
- Primary Rater: The Station Commander
- Categories: 32
166
F-1142A
Daily Probationary Report
- Completed each shift and reviewed with probationary firefighters
- Copies: 3
- Forward: With 10 Shift Evaluation
- Retain: 5 years at Recruit Training
167
F-1142C
Probationary Performance Log
- Used to maintain Record of daily reports
- Copies: 3
- Forward: with 10 Shift Evaluation
- Retain: 5 years at Recruit Training
168
F-1150
Outside Employment Report
_ * Request for Outside Employment
- Copies: 2 (1) members folder, (1) Personnel
- Routing Original: Through channels to Fire Chief
- Routing Annual Update: Through channels to ERO
- Disapproval: Officer attaches and forwards F-225
169
F-1202
Weight Control Report
- Copy: 1
- Forward: Members Dr. or Batt, forward MONTHLY, First working shift of month.
- Routing: MLU
170
F-1307
Cleaned by Owner
- Brush Clearance Form used to document COMPLIANCE
- Copies: 3
- Retain: 3 years at Station, 5 years at Brush Unit
- Forward: Within 24 hours after entry on the F-1308
171
F-1308
Brush Clearance Notice of NON-Compliance
- For Improved/Unimproved Properties (Mt Fire District/Mt Washington)
- Used for weeds and grass on improved properties ONLY outside of these areas.
- Copies: 4
- Retain: 3 years at Station, 5 years at Brush Clearance
172
F-1309
Brush Clearance Information Sheet
- Distributed to citizens, assigned to Brush Area. May be mailed.
173
NOTE: F-3000, F-3001, and F-3002
Alcohol/Substance Abuse Forms
174
F-3000
Employee's Physical Characteristics/Behavior
- Issued by Supervisor with F-225 attached
175
F-3001
Order for Urine Sample
- Issued: PSD to member with Union Representative
176
F-3002
Employee Voluntary Urine Sample
- Issued: PSD to member with Union Representative
177
F-5054
Weekly Time Sheet Overtime and Exception Report
- Copies:2
- Retain: 2 years
- Forward: Through channels to headquarters every SUNDAY
- Pay Period: Begins and Ends at 0800 hrs every OTHER Sunday
- Weekly Reporting: Begins and Ends at 0800 every Sunday
- Entries: Entries made at station where the member's name is preprinted on 5054s
-* Do NOT line out or write members name because of transfer
- Not Working: Make entries whenever member's is not working regular assigned hours or when member is on light duty
+ No Entry on 5054:
1. Holiday working or taking off
2. Administrative Time Off
3. Administrative Details
4. Trades
178
F-5054A
FLSA Overtime Report
- Copies: 2
- Retain: 3 years
- Forward: To Accounting end of FLSA period, when transferring to special duty or vice versa
179
Cal OSHA 200
- Used for employee ANNUAL log and summary of Cal OSHA Recordable occupational injuries and illnesses
- Complete: January following calendar year
- Copies: 2
- Retain: 5 years after end of calendar year
- Forward: Duplicate to Occupational Safety Officer
- Post on Official Business Bulletin Board: No later than February 1 and shall remain in place until March 1
- NOTE: 24 hrs equals 2 work days (12 hrs each)
180
Cal OSHA 300
Annual Summary of Work Related Injuries and Illnesses
- Post new calendar year Cal OSHA 300 every February 1 to April 30th on the Department Official Bulletin Board
- Must complete form even if no injuries occurred during calendar year
- If no cases of injury, Enter "0"
