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Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV VF-VAW-11C - New York
| Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. VOLUNTEER'S NOTIFICATION OF EXECUTIVE OFFICER OF FIRE/AMBULANCE COMPANY OF SIGNIFICANT RISK OF TRANSMISSION OF HIV PER VFBL/VAWBL SECTION 11-c(1) Notice to the Executive Officer of a Fire Company/Ambulance Company that a volunteer firefighter/volunteer ambulance worker has been exposed to a significant risk of transmission of the Human Immunodeficiency Virus (HIV) while performing services in the line of duty. VFBL/VAWBL Section 11-c(1) requires the Executive Officer of a Volunteer Fire/Ambulance Company to authorize a volunteer firefighter/volunteer ambulance worker to obtain an appropriate medical examination to determine if such volunteer firefighter/ambulance worker has been exposed to or infected with HIV within 8 hours of receipt of the notice of an incident that has created an exposure risk to the volunteer firefighter/ambulance worker to HIV while performing services in the line of duty. INSTRUCTIONS TO VOLUNTEER: PRESENT THIS FORM TO THE EXECUTIVE OFFICER OF FIRE/AMBULANCE COMPANY. SEND A COPY TO THE WORKERS' COMPENSATION BOARD (SEE MAILING ADDRESSES AND PERSONAL PRIVACY PROTECTION NOTIFICATION ON REVERSE). NAME OF VOLUNTEER FIREFIGHTER/AMBULANCE WORKER DATE OF BIRTH SOCIAL SECURITY NO. TELEPHONE NUMBER SEX RESIDENTIAL ADDRESS MAILING ADDRESS, IF DIFFERENT NAME AND ADDRESS OF FIRE/AMBULANCE COMPANY TELEPHONE NUMBER DATE AND TIME OF EXPOSURE SPECIFIC PARTS OF BODY EXPOSED ADDRESS WHERE EXPOSURE OCCURRED WITNESSES, IF ANY HOW DID EXPOSURE OCCUR? ______________________________________________________ ________________ ___________________________________ Signature of Volunteer Firefighter/Ambulance Worker Date Signed Time of Submission to Executive Officer FOR USE BY EXECUTIVE OFFICER OF FIRE/AMBULANCE COMPANY The volunteer firefighter/ambulance worker named above is authorized to obtain an appropriate medical examination to determine if he/she has been exposed to or infected with the human immunodeficiency virus (HIV). _______________________________ _________________________________ ____________ Name of Executive Officer Signature of Executive Officer Date ___________________ Time of Approval VF/VAW-11C (1-11) American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.state.ny.us Statewide Fax Line: 877-533-0337 ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all incidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all incidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all incidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all incidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all incidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 eek. (866) 746-0552 For all incidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a). The Workers' Compensation Board's ("Board's") authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers' Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records. The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law. The Board's Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency records containing personal claimant information. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your case. VF/VAW-11C (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com
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