TVA - NOTICE OF VEHICULAR ACCIDENT

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• ENERGY DELIVERY INITIAL REPORT OF A MOTOR VEHICLE ACCIDENT

• Name of TVA DRIVER:

• Employee ID:

• Job Classification:

• Date / Time of,Accident:

  Date

• Date / Time Reported to Foreman/Supervisor:

  Date

• Date / Time Reported to Management:

  Date

• Accident Location:

• Local Police called?

  YES

  NO

• TVA POLICE called?

  YES

  NO

• TVA Vehicle Involved (include tag#)

• Damage to TVA Vehicle?

  YES

  NO

• TVA VEHICLE PIC#1

  Media

• TVA VEHICLE PIC#2

  Media

• TVA VEHICLE PIC#3

  Media

• Damage to Other Vehicle?

  YES

  NO

• OTHER Pic#1

  Media

• OTHER Pic#2

  Media

• OTHER Pic#3

  Media

• Foreman / Construction Foreman / Supervisor:

• Any Injuries?

  YES

  NO

• Any Blood Exposure? If Yes, whose blood and who was exposed?

  YES

  NO

• List Names:

• Witnesses? If Yes, list their names.

  YES

  NO

• LIST Names:

• DESCRIPTION OF HOW ACCIDENT OCCURRED?

• Any Other Information?

• Name of Person Completing this Notice:

  Robert L. Barnes - Safety Consultant-Huntsville

  John B. Westmoreland, Jr - Huntsville-TSM

  Harold Joly - Muscle Shoals-TSM

  Philip Stovall - ROM

  Tammy Young - TOM-Nuclear TSM

CC: Patrick Taylor / Tony Cameron / Business Unit VP / Responsible Supervisor / Responsible Manager / TVA Area Safety Consultant