CVA INCIDENT REPORT - duplicate

• Site

  Select

• Report Type

  Workplace Injury

  Motor Vehicle Incident

  Other Incident

• Incident Title (Employee Name or Short Incident Description)

• Conducted on

  Date

• Prepared by

INCIDENT DESCRIPTION

• Employee(s) Involved

• Describe how the incident occurred (Include work being performed , how the incident occurred, include photos here to illustrate how incident happened).

• Describe injuries that resulted from incident.

DATE/TIME

• Date of Incident?

  Date

• Date Supervisor was first notified

  Date

• Date Safety Team was notified

  Date

LOCATION

• Incident occurred at a CVA Facility

• CVA Branch (Town/Division)

• Describe area within facility (shop, office, etc.)

• Incident Occurred on a Public Road

• State

• County

• Town or City (if occurred in city limits)

• Road or Highway

• Nearest Mile Marker or Intersecting Road

• Location Pin if available
  Address

• Incident Occurred on Private Property

• State

• County

• Nearest Town or City

• Property Owner Name and Contact Information

• Description of location

• Location Pin if available
  Address

SUPERVISOR INFORMATION

• Supervisor Name

• Supervisor Phone Number

• Check Box to use this section

Employee Information

• Employee Name

• Employee ID Number

• Employee Address

• Employee Phone

• Employee Emergency Contact Person and Phone Number

• First Aid received?

• Who performed the first aid

• Describe the first aid performed

• Treatment received at a Medical Facility

Medical Care

• Ambulance/Life Flight Service Used

• Name of Ambulance Service

• Phone Number for Ambulance service

• Medical Facility

• Medical Facility Name and Address

• Phone Number for Medical Facility

• Treating Physician (if known)

• Describe Medical Care Provided at this facility (Inpatient or Outpatient and exams or treatment if known).

• Employee transferred to other facility for additional care

• Medical Facility Name and Address

• Phone Number for Medical Facility

• Treating Physician (if known)

• Describe Medical Care Provided at this facility (Inpatient or Outpatient and exams or treatment if known).

• Describe any work restrictions provided. (Include a photo of the doctor's work restrictions note if available).

• Check box to use this section

Incident Information

• Describe the weather and road surface conditions

• Incident Diagram / State Motor Vehicle accident diagram (notes and photos)

• Incident Scene Notes and Photos (take images from distance to capture road departure, vehicle position, etc.)

• Law Enforcement Agency that performed investigation

• Investigating officer name/badge/phone

Witness Information

• Name of Witness

• Witness Phone Number

• Witness Statements

Property Damage Information

• Describe any property damage resulting from the incident

• Owner of property and phone number (if known)

• Images of property damage (Notes and Photos)

CVA Vehicle(s) and occupant(s) Involved in accident

• Driver Name

• Was driver wearing a seatbelt?

  YES

  NO

• Driver's License State / Number (add photo optional)

• Names of all other vehicle passenger(s), their position in the vehicle

• Known injuries/condition of driver and occupants

• Were occupants wearing seat belts?

• Other notes about vehicle driver/occupants (age, sex, intoxication, comments, etc.)

• Vehicle Year / Make / Model

• Vehicle Odometer

• Registration State/License (add photo optional)

• Insurance company, policy number, agent, phone (add photo optional)

• Description of Vehicle Damage (add photos)

• Was this vehicle towed?

  YES

  NO

• Name of Towing Company?

• Where was vehicle towed?

• Was vehicle pulling a trailer?

  YES

  NO

• Trailer Year / Make / Model

• Registration State and License (Photos optional)

• Description of Trailer Damage (Add photos)

• Was this vehicle towed?

  YES

  NO

• Name of Towing Company?

• Where was vehicle towed?

OTHER Vehicle(s) Involved in accident

• Driver Name

• Was driver wearing a seatbelt?

• Driver's license State/Number (Photo Optional)

• Total number of passengers including driver

• If driver or occupants were injured describe known injuries/condition

• Were occupants wearing seatbelts?

• Other notes about vehicle driver/occupants (age, sex, intoxication, comments, etc.)

• Ambulance and hospital information for driver or passengers

• Vehicle Owner

• Vehicle Year / Make / Model

• Vehicle Odometer

• Registration State / License (Photo optional)

• Insurance company, policy number, agent, phone (Photo optional)

• Description of Vehicle Damage (Add Photos)

• Was this vehicle towed?

  YES

  NO

• Name of Towing Company?

• Where was vehicle towed?

• Was vehicle pulling a trailer?

  YES

  NO

• Trailer Year / Make / Model

• Trailer registration (Photos Optional)

• Photos of trailer damage (Add Photos)

• Was this vehicle towed?

  YES

  NO

• Name of Towing Company?

• Where was vehicle towed?

• Check box to use this section

Chemical Release Information

• Product Spilled/Released

• Amount Spilled/Released

• Describe how the spill/release occured

Photos

Photo

• Spill Site Photos and Notes

Emergency Response

• Emergency Departments/Teams who Responded to Incident

• Describe how the area was isolated after the release

• Other emergency processes or procedures performed

Regulatory Reporting

• Regulatory Agency The Spill Was Reported To

• Date and Time of Report

  Date

• Contact Person / Phone Number

• Notes Pertaining to Spill Reporting

Containment / Clean-up

• Describe how the spill was contained

• Describe how the site was cleaned

• Describe how contaminated materials/soils were disposed

Photos and Notes

• Clean-up Photos and Notes

• Check box to use this section

Incident Description

• Person(s) involved

• Description of how Incident occurred

• Resulting Damage

Incident Photo #

• Photos and Notes

Witness Information

• Witness Name

• Witness Phone Number

• Witness Statements

• Check box to use this section

DRUG AND ALCOHOL TESTING INFORMATION

• Name of Person Tested?

• Type of testing performed?

  Select Non-DOT Reasonable Suspicion Alcohol Test Non-DOT Reasonable Suspicion Drug Test DOT Reasonable Suspicion Alcohol Test DOT Reasonable Suspicion Drug Test DOT Post Accident Alcohol Test DOT Post Accident Drug Test

  • Non-DOT Reasonable Suspicion Alcohol Test
  • Non-DOT Reasonable Suspicion Drug Test
  • DOT Reasonable Suspicion Alcohol Test
  • DOT Reasonable Suspicion Drug Test
  • DOT Post Accident Alcohol Test
  • DOT Post Accident Drug Test

• Date and time collection was made?

  Date

• Person or Facility performing drug testing collection?

• Other Notes

• Check box to use this section

OSHA REPORTING INFORMATION

• Reported by

• Date and Time

  Date

• Describe method of reporting (Online, Phone, Etc)

• OSHA Agent taking the report / contact info if available

• OSHA Report Number

• Other Notes

Root Causes

• Describe root causes and/or contributing factors.

Corrective Actions

• Describe corrective actions necessary to prevent future similar incidents.

• Signature of incident investigator

  Sign