四色AV

ACCIDENT INVESTIGATIONS

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Employee听Incident/Accident Investigation Form - DA2000听
Student/Visitor/Client Accident Reporting Form - DA3000听
State Vehicle Incident Report Form - DA2041听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 听 Vehicle Glass Damage - DA2073

Instructions

The Office of Risk Management Incident/Accident Investigation Forms DA2000 and DA3000 are tools to assist in determining the causes and procedures to prevent the recurrence of similar incidents. All spaces on the forms are to be completed. Use N/A if a question does not apply to the accident. Do not leave blank lines. Never give a copy of the completed form to the injured party.

For any bodily injury or property damage, and in most cases, dial 342-5350 first for 四色AV Police.听

Employees听

1. A DA2000 must be filled out when someone who receives a paycheck from 四色AV has sustained bodily injury.
2. The first employee to reach the accident scene is responsible for initiating the report. A completed report (DA2000) must be returned to EHS office within 24 hours of the accident.
3. Go to the immediate area of the accident.
4. Follow recommended emergency first aid procedures, as outlined. Once the safety of the employee has been assured, a report of the accident must be made.
5. Contact EHS office immediately (342-5177) and then your supervisor.
6. Ask the person or persons involved to describe what happened, if possible. Do not fix blame or find fault; just get the facts.
7. Survey the accident scene for information. Assemble any objects that might have contributed to the accident. Take multiple pictures of everything.
8. Determine if there were any witnesses to the accident and get their signed and dated, written accounts of the incident.
9. Take whatever steps are necessary to prevent recurrences until the condition can be permanently corrected.
10. A supervisor must complete lines 16 through 23 and the Root Cause Analysis.

Everyone Else

1. If anyone is injured on campus听who听does not receive a paycheck from 四色AV, a DA3000 must be filled out.
2. Write a complete report, using the accident/incident form DA3000. The first employee to reach the accident scene is responsible for initiating the report. Completed report must be returned to the EHS office within 24 hours of the accident.
3. Go to the immediate area of the accident.
4. Follow recommended emergency first aid procedures, as outlined. Once the safety of the student/non-employee has been assured, a report of the accident will be made.
5. Contact EHS office immediately (342-5177) and then your supervisor.
6. Remind the students/non-employee that the purpose of the investigation is to determine cause.
7. Talk with the injured person(s) and/or witnesses to get the facts. Ask the student/non-employee for his or her version. Have witnesses follow up with written statements of what they saw and heard (facts only, not opinion or speculation).
8. Listen for clues in the conversation that might reveal accident causes. Take multiple pictures of everything.
9. Encourage the discussion of ideas for corrective action.
10. Study the possible causes.
11. Follow up to make sure all of the causes are corrected.

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Remember that no accident investigation is complete until corrective action has been implemented. Use caution in filling out the form. Avoid making statements that indicate corrective action was taken as a result of the investigation. This shows that a corrective solution was available.听

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Property Damage

If you have property damage in your area, call the Facilities and Environmental, Health & Safety Office at 318-342-7929.