Appendix A - USAFE Base IMT 50.pdf
PDF 12 KB Posted
- Attached to
- Portuguese Civilian Employee Insurance Coverage
- Solicitation number
- FA448622R0014
About this file
This document contains an injury report form template for Portuguese civilian employees and information on a federal contract opportunity for providing insurance coverage to those employees. The form requires reporting of details of an accident within 24 hours such as date, time, location, description of the incident, treatment received, and supervisor signature.
The solicitation seeks a contractor to provide all necessary insurance coverage as required by Portuguese law for job-related accidents, injuries, illnesses, and accidents or injuries that occur during temporary duty travel. This includes total liability transfer for such incidents involving Portuguese civilian employees of United States Forces Azores stationed at Lajes Field in the Azores, Portugal under both appropriated and non-appropriated funding. The solicitation was issued by the Department of the Air Force United States Air Forces in Europe - Air Forces Africa.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
To be prepared and submitted within 24 hours after the accident
(Describe what worker was doing and how the accident happened) (Descreva o que o trabalhador estava a fazer e como o acidente aconteceu))
This form contains personal information - Safeguard accordingly (Este documento contem informações Pessoais - Guardar convenientemente)
REPORT OF INJURY FOR PORTUGUESE EMPLOYEES
(PARTICIPAÇÃO DE LESÕES DE EMPREGADOS PORTUGUESES)
I. ROUTING
(ENCAMINHAMENTO Para ser preparado e submetido em 24 horas após o acidente)
(CPF, SE and Insurance Company/
II. INJURED EMPLOYEE INFORMATION (INFORMAÇÃO DO EMPREGADO)
(YYYYMMDD)
(YYYYMMDD)
1. TO (PARA)
3. NAME
17. ACCIDENT OCCURED
18. TREATMENT
20. LOCATION OF ACCIDENT
19. DUTY SCHEDULE
13. HOME ADDRESS 14. CONTACT
a. HOME PHONE b. CELL PHONE
(CONTACTO)
(TELEFONE DE
ACIDENTE)
(DATA DO
(TRATAMENTO) (HORÁRIO TRABALHO)
(NA BASE) (FORA NA BASE)
(HORA DO ACIDENTE)
(LOCAL DE OCORRÊNCIA)
Safety, Seguradora) Esc. Pessoal Civil, CASA)
(MÓVEL)
15. DATE OF ACCIDENT
21. DESCRIPTION OF ACCIDENT
22. SUPVERVISOR'S NAME 23. SUPERVISOR'S SIGNATURE 24. DATE(NOME DE SUPERVISOR)
(ASSINATURA DE SUPERVISOR)
(DATA)
(DESCRIÇÃO DO ACIDENTE
16. TIME OF ACCIDENT
5. AGE 6. GENDER
M
4. BADGE NUMBER
11. PAY GRADE 12. OCCUPATION
2. FROM (DE) (Organization/ Organização)
(NOME) (N.° ID) (IDADE) (SEXO)
USAFE BASE IMT 50, 20060701, V1 FOR OFFICIAL USE ONLY (When Filled In)REPLACES LAJES FIELD FORM 50, 19910701, WHICH IS OBSOLETE
DESIGNED ONLY FOR USE AT LAJES FIELD, AZORES PORTUGAL
F
7. PORTUGUESE ID
9. MARTIAL STATUS 10. DEPENDENTS
8. PLACE OF BIRTH(BI N.°) (LOCAL DE NASCIMENTO)
(EST. CIVIL)
(CAT. PROFISSIONAL)
(MORADA)
(FUNÇÃO)
(FILHOS A CARGO)
(NÃO) (SIM)NO YES
III. ACCIDENT INFORMATION (INFORMAÇÃO REFERENTE AO ACIDENTE)
ON BASE OFF BASE
(EM SERVIÇO) (FORA DO SERVIÇO)
ON DUTY OFF DUTY
(CUIDADOS MENORES)
MINOR CARE
(CUIDADOS MAIORES)
(LOCAL DO ACIDENTE)
MAJOR CARE
(NORMAL)
NORMAL
(TURNO FIXO)
FIXED SHIFT
(TURNO ROTATIVO)
SHIFT ROTATION
(OUTRO)
OTHER
IV. VALIDATION (VALIDAÇÃO)
File details come from the government source that posted it. Updated .