Tsp Form 21 PDF Details

In March 2011, Chevron Corporation introduced the Work-Related Injury/Illness Case Management Procedure, known as the TSP-21 form, as a comprehensive guideline for managing cases of injuries or illnesses that occur at work, specifically tailored for contractor communication within its Thailand Profit Center. This procedure underscores the importance of providing immediate and appropriate medical treatment to the injured or ill individuals, ensuring a thorough follow-up until they are fit to return to work, and facilitating effective communication and coordination among supervisors, affected management personnel, Chevron's Operational Excellence/Health, Environment and Safety (OE/HES) Department, Chevron Medical staff, management of contractor companies, third-party contracted medical services, and treating doctors in onshore clinics or hospitals. The document outlines clear objectives, including ensuring injuries or illnesses are classified accurately and consistently with Chevron's OE Data Requirements without limiting the treatment to suit case definitions. It also defines the scope of the procedure, which applies to all work-related injuries or illnesses affecting all employees and contractor personnel working under Chevron Thailand Exploration and Production, Ltd. (CTEP) Operational Control at all onshore and offshore locations, including the Bangkok office. Furthermore, it specifies initial and follow-up treatment facilities for work-related injuries/illnesses, emphasizing the use of designated hospitals and the process for considering other hospitals on a case-by-case basis. This structured approach highlights Chevron's dedication to employee and contractor health, safety, and welfare within its operational territories.

QuestionAnswer
Form NameTsp Form 21
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namestsp 21, tsp form 21g pdf, tsp 21 g pdf, printable tsp 21 g form

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W or k - Re la t e d I n j u r y / I lln e ss Ca se M a n a g e m e n t Pr oce d u r e ( TSP- 2 1 )

For Cont ract or Com m unicat ion

Thailand Pr ofit Cent er

Mar ch 2011

© 2011 Chevron Corporation. All rights reserved.

Case Managem ent - Pur pose and Obj ect ives

To ensur e t hat appr opr iat e m edical t r eat m ent is pr om pt ly pr ov ided t o t he inj ur ed / ill per son

To ensur e appr opr iat e follow up on cases unt il t he inj ur ed / ill

per son is fit for r et ur ning t o w or k

To ensur e effect ive coor dinat ion and com m unicat ion bet w een super v isor and affect ed Managem ent Per sonnel of t he inj ur ed/ ill per son, CTEP’s OE/ HES Depar t m ent , CTEP Medical st aff, along w it h m anagem ent of cont ract or com panies, 3 r d Par t y Cont ract ed Medical Ser v ices, and Tr eat ing Doct or s in onshor e clinics or hospit als

To ensur e inj ur ies or illnesses ar e classified in an accurat e and consist ent m anner accor ding t o t he Chev r on OE Dat a Requir em ent s w it h no int ent ion t o lim it t he t r eat m ent t o suit t he case definit ions.

© 2011 Chevron Corporation. All rights reserved.

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Case Managem ent - Scope

The pr ocedur e is applicable t o all w or k- r elat ed inj ur ies or illnesses affect ing all em ployees and Cont ract or per sonnel w or k ing under Chev r on Thailand Ex plorat ion and Pr oduct ion, Lt d. ( CTEP)

Operat ional Cont r ol at all onshor e and offshor e locat ions, including t he Bangkok office.

© 2011 Chevron Corporation. All rights reserved.

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I nit ial Tr eat m ent Facilit y for Wor k - Relat ed I nj ur ies/ I llnesses

All w or k- r elat ed inj ur ies/ illnesses r efer r ed t o an onshor e hospit al for

t r eat m ent by a Chev r on Doct or or Medic w ill init ially be sent t o only t he follow ing designat ed hospit als:

Bangkok- Hat yai Hospit al, Songk hla

Bangkok - Pat t aya Hospit al, Chonbur i

Nak har in Hospit al, Nakor n Sr i Tham m arat

Vibhavadi Hospit al, Bangkok

I n cases w her e a w or k- r elat ed inj ur y or illness occur s at onshor e locat ions away fr om t he designat ed hospit als, e. g., inj ur y r elat ed t o m ot or vehicles, considerat ion should alway s be given t o use t he near est hospit al available,

depending on locat ion of incident and t he sever it y of inj ur y or illness.

Cont ract or s w ishing t o use anot her hospit al ot her t han t he appr oved Chev r on designat ed hospit als w ill be consider ed on a case- by- case basis

aft er discussion and appr oval fr om CTEP Healt h and Medical Ser v ices ( H&MS) Depar t m ent .

© 2011 Chevron Corporation. All rights reserved.

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Follow - up Tr eat m ent Facilit y for Wor k- Relat ed

In j ur ies/ I llnesses

Aft er an init ial diagnosis and t r eat m ent , a cont ract com pany m ay t ransfer an I nj ur ed/ I ll Per son ( I P) t o anot her hospit al for fur t her t r eat m ent and follow up w it h concur r ence fr om t he Chev r on on dut y Medical Doct or and r elevant Chev r on Depar t m ent al Manager. The I P’s em ployer m ust coor dinat e w it h t he Chev r on H&MS st aff in pr ov iding t he I P’s st at us on a daily basis unt il

t r eat m ent is concluded or t he I P is dischar ged fr om t he hospit al. A m edical cer t ificat e or dischar ge sum m ar y should be obt ained and sent t o Chev r on H&MS.

I f t he I P is due t o go off dut y and t he inj ur y / illness has not com plet ely

healed or a full r ecover y m ade, t he super v isor of t he I P shall consult t he Chev r on H&MS on dut y Doct or w ho m ay r ecom m end t hat t he per son r em ain w it h pay at an onshor e facilit y w hich has access t o a m edical facilit y.

I n any case w her e t he I P is r eleased t o go hom e w it h m edical pr ecaut ions, t he I P m ust st r ict ly follow t he m edical inst r uct ion given.

© 2011 Chevron Corporation. All rights reserved.

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Follow - up Tr eat m ent Facilit y for Wor k- Relat ed

In j ur ies/ I llnesses

To r et ur n t o w or k, t he com pany r epr esent at ive m ust pr esent t he

r et ur n t o w or k or final m edical cer t ificat e r eceived fr om t he t r eat ing hospit al/ clinic t o t he Chev r on H&MS ( Sat t ahip, Songk hla, Nakor n Sr i Tham m arat or Bangkok ) for evaluat ion at least 3 w or k ing day s pr ior t o r et ur ning t o w or k . Medical decisions on fit ness for dut y w ill be

m ade by t he Chev r on on dut y Medical Doct or only.

© 2011 Chevron Corporation. All rights reserved.

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CTEP Medical Per sonnel and Thir d Par t y Medical Ser v ice Pr ov ider Per sonnel

For any t r eat m ent t hat is likely t o go beyond fir st aid, t he Facilit y Medic shall consult w it h t he Chev r on on dut y Medical Doct or. I f t he Facilit y Medic is under a t hir d par t y m edical ser v ice pr ov ider, t he Cont ract Medic shall consult w it h t he t hir d par t y Medical Ser v ice Pr ov ider Doct or w ho w ill cont act and discuss t he t r eat m ent opt ions w it h t he Chev r on on dut y Medical Doct or.

I n t e r a ct ion b e t w e e n CTEP M e d ica l Pe r son n e l a n d Tr e a t in g D oct or ( s)

Com m unicat ion bet w een Chev r on m edical per sonnel and Tr eat ing Doct or s is cr it ical,

and it m ust be done in a pr ofessional and et hical m anner. Aut hor it y and decision t o t r eat an I P lies w it h Tr eat ing Doct or s w it h t he concur r ence of t he inj ur ed/ ill per son; how ever, Chev r on m edical per sonnel m ay consult w it h Tr eat ing Doct or s t o ensur e consist ent case m anagem ent .

To avoid confusion and m isunder st anding, no one ot her t han assigned Chev r on m edical

per sonnel shall int er fer e w it h Tr eat ing Doct or s. Cont ract or s’ r epr esent at ives or 3r d par t y m edical ser v ice pr ov ider shall consult t he Tr eat ing Doct or s t hr ough Chev r on assigned m edical per sonnel.

© 2011 Chevron Corporation. All rights reserved.

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Role and Responsibilit ies – All Em ployees and Cont ract or s

Not ify super v isor im m ediat ely and seek pr om pt m edical at t ent ion

follow ing an inj ur y or suspect ed w or k- r elat ed inj ur y or illness

Pr ov ide an accurat e descr ipt ion of t he suspect ed w or k- r elat ed inj ur y

or illness t o super v isor and m edical pr ov ider

Pr ov ide an accurat e descr ipt ion of any concur r ent m edical condit ions and/ or t r eat m ent s t o m edical pr ov ider

Adher e t o t r eat m ent pr escr ibed, w or k r est r ict ions, and com m unicat ion r equest s of Tr eat ing Doct or / Medic

Com plet e Per m ission t o Release I nfor m at ion For m

© 2011 Chevron Corporation. All rights reserved.

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Role and Responsibilit ies – Super v isor of

I ll/ I nj ur ed Per son

Repor t k now n w or k- r elat ed inj ur y / illness case accor ding t o incident not ificat ion and invest igat ion pr ocedur e

Conduct incident invest igat ion of w or k- r elat ed inj ur y / illness and r ecor d

r elevant infor m at ion

I f t her e is r eason t o believe dr ugs or alcohol m ay be a cont r ibut ing fact or t o

 

t he incident , considerat ion should alway s be given t o r equest ing t he

 

 

 

Chev r on Medical Doct or / designee t o conduct a Dr ug & Alcohol t est on t he

 

I P and/ or any ot her per sonnel dir ect ly involved in t he incident , w hen t he I P

 

is r efer r ed t o an onshor e m edical facilit y. This should be done follow ing t he

 

Dr u g & Alcohol Test ing and Subst ance Abuse Policy

I f t he case involves a cont ract em ployee, ensur e t he Cont ract Com pany Repr esent at ive has been not ified.

Not ify HR t o keep a r ecor d of t he indiv idual’s work- r elat ed inj ur y / illness, including sick leave, com pensat ion, et c.

Discuss w it h CTEP Doct or t o assign appr opr iat e dut ies t o t he I P follow ing appr oval for r et ur n t o w or k .

© 2011 Chevron Corporation. All rights reserved.

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Role and Responsibilit ies – Manager of t he I ll/ I nj ur ed Per son

Coor dinat e w it h t he Facilit y Medic and ar range necessar y m edical t ranspor t at ion ar rangem ent s

Ensur e appr opr iat e r esour ces ar e allocat ed t o m anage t he case upon not ificat ion of w or k r elat ed- inj ur y / illness

Com m unicat e t o all per sonnel at t he facilit y t hat a Dr ug & Alcohol t est m ay

be conduct ed on t he I P and any ot her per sonnel dir ect ly involved in t he incident in w hich t he I P is r efer r ed t o an onshor e m edical facilit y

Rev iew fact s w it h Facilit y Medic or w it h Chev r on on dut y Medical Doct or or 3 r d Par t y Medical Doct or im m ediat ely follow ing diagnosis and t r eat m ent for

all w or k- r elat ed inj ur y / illness cases t hat have t he pot ent ial t o r esult in any w or k r est r ict ions

Rev iew Wor k Rest r ict ions or Fit t o Ret ur n t o Wor k st at us w it h Chev r on on

dut y Medical Doct or and super v isor of t he I P. Not ify t he next level of

m anagem ent of any I P w hose inj ur y / illness m ay r esult in w or k r est r ict ions

Suppor t t he assignm ent of appr opr iat e dut ies t o t he I P follow ing appr oval for Ret ur n t o Wor k w it h adv ice fr om t he CTEP Doct or

© 2011 Chevron Corporation. All rights reserved.

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Roles & Responsibilit ies - 3 r d Par t y Medical Ser v ices Doct or

Cont act t he Chev r on on dut y Medical Doct or t o discuss t he pr oposed init ial t r eat m ent befor e adv ising t he Facilit y Medic at t he offshor e locat ion

Adv ise 3 r d par t y Medic on diagnosis and t r eat m ent in w r it ing. The only except ion t o t his w ould be an em ergency sit uat ion, or if t her e is an I T com m unicat ions br eak dow n ( e- m ail) . I n t his case, ver bal com m unicat ions

fr om t he Doct or is accept able, but m ust be docum ent ed and for war ded once com m unicat ions have been est ablished

I f r e q u ir e d , coor d in a t e ca se m a n a g e m e n t w it h t h e h osp it a l Tr e a t in g D oct or on sh or e t h r ou g h t h e Ch e v r on On sh or e M e d ica l Coor d in a t or on ly ( n o d ir e ct con t a ct w it h Tr e a t in g D oct or )

© 2011 Chevron Corporation. All rights reserved.

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