HomeMy WebLinkAboutAccident or Incident ReportReport Control #________- __ __ __ __
(year)
Instructions: Complete applicable sections; forward copies to City Manager's Office.
Accident Incident Property Damage Employee Injury
WHO Name:
Employee Full Time Part Time Volunteer Private Citizen
WHAT Describe what happened leading up to, during, and immediately after the accident.
WHERE Specifically where did the accident occur? (address, intersection of, building room, etc.)
WHEN Date/Day_________________________Time____________________________AM/PM
WHY
Cause Code(s):
Equipment/Material Unsafe Conditions
1. Ineffectively guarded equipment 17. Poor light
2. Unguarded equipment 18. Poor ventilation
3. Defective tool(s)19. Congestion
4. Defective material(s)20. Improper Storage
5. Defective equipment 21. Exit(s) inadequate/not provided
22. Faulty layout of facility
Employee Characteristic 23. Tool, equipment, or materials scattered around
6. Haste, shortcuts & chance-taking 24. Slippery floor
7. Guards provided but not used 25. Unsafe - caused by others
8. Personal safety devices furnished but not used 26. Fire & explosion hazard
9. Improper or unsafe tool or equipment used 27. Inadequate warning system
10. Horseplay 28. Adverse weather condition
11. Not following rules & instructions 29. Other
12. Inattention
13. Inexperience Assault/Caused by Others
14. Physical condition
15. Improper body position
16. Operating without authority
INJURIES SUSTAINED Yes No If yes, complete Section A on reverse
PROPERTY DAMAGE Yes No If yes, complete Section B on reverse
City of Atascadero
Accident/Incident Report
Determine the cause of the accident. (Site location assessment; equipment/vehicle condition;
employee training/limitations; weather, etc.
Report Control #________- __ __ __ __
(year)
SECTION A - INJURY(IES) SUSTAINED
What is/are the injury(ies)? (strain, sprain, cut, bruise, etc.)
List body part(s) involved. Be specific (i.e., left, right, uppper, lower, first, second, etc.)
Action Taken / Treatment Received:First Aid Doctor
Emergency Medical Personnel Hospitalized None
Lost time from work?Yes No
(If yes, date of first day lost and estimated date of return to work)
SECTION B - PROPERTY DAMAGE
CITY OWNED PROPERTY
SUBROGATION POTENTIAL:Yes No Amount $_______________
PRIVATE PROPERTY
HISTORY Has the employee been involved in similar accidents? Yes No
If yes, list Report Control Number(s):
Staff / Employee Recommendations:
Action Taken by Supervisor & Department:
Supervisor Signature/Date
Division Head Signature/Date
Department Head Signature/Date
City Manager's Office Signature/Date
Describe what was damaged and the type and extent of damage. Include inventory control
number, if applicable and available.
Describe what was damaged and the type and extent of damage. Include address(es) and phone
number(s) of owner(s)