ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES

ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES VEHICLE ACCIDENTS/PROPERTY DAMAGE Non-Workers Compensation Accident Report Form Attached is a sample copy of the accident report for vehicle damage, which is to be completed as soon as possible after an accident. It is the employee s responsibility to immediately report any and all incidents, regardless of severity, to the supervisor. The supervisor will then conduct a personal investigation of the accident location, as well as the working conditions at the accident location; question all persons involved, including any witnesses and coworkers, regarding observation of events prior to, during and after the accident; inspect any tools, materials, equipment or vehicles involved in the accident; obtain necessary evidence including photographs, written statements, material samples, etc.; complete all appropriate accident/injury forms in, ink and return completed forms to the Administrative Assistant within 24 hours of the accidents occurrence. The Administrative Assistant will distribute the report accordingly. Application of this report pertains to any accident involving a municipal vehicle, whether the vehicle is licensed, or an off road unlicensed vehicle. This report form should be utilized in the following instances: 1. Municipal vehicle collides with another vehicle or vehicles. 2. Municipal vehicle collides with another party s property (i.e. fence, utility pole, building, etc.). 3. Municipal vehicle is involved in a single vehicle accident (i.e. runs off the roadway), or road collision accident (i.e. strikes a pot hole or debris on roadway). 4. Municipal vehicle strikes pedestrian(s), bicyclist, animal, or object. 5. Municipal vehicle damaged by vandals, weather, or any loss other than collision. 6. Damage to mobile equipment (i.e. tractor, chipper, cherry picker, etc.). The front side of this form is to be filled out by the employee who was either in the accident in question, or in charge of the vehicles/equipment. The supervisor is to secure as much information as possible. This side of the Non-Workers Compensation Accident Report Form allows space for the municipal driver s brief statement of facts. The reverse side of this form must be completed by the employee s supervisor, superintendent, or department head only after the employee has filled out the front side and discussed the accident in detail with the same. The last section of the report is essential to the handling of any vehicle-related accident. This section allows the employee s immediate supervisor the opportunity to express an opinion as to the degree of responsibility borne by the employee in contributing to or causing the accident. The report should be accompanied, or followed shortly thereafter, by a police report. In the event that the vehicle is a potential economic total loss, Administrative Assistant for Human Resources, should be notified immediately to contact IRMA.

of 9 How to Complete Non-Workers Compensation Accident Report Forms I. Member Information Name of IRMA Member (Municipality): The City of Lake Forest Contact Person Name and Phone Number: DeSha Kalmar, 847-615-4268 Department: Public Works or Parks & Recreation Date of Loss: Date of the accident Time of Loss: Time of the accident Estimate or Loss Damage $: Number should come from Fleet if for vehicle damage, Building Maintenance if for building damage. Was Employee Injured: Check one Location of Loss: Where the accident occurred Employee Name: Name of employee Employee Status: Check one Police or Fire Dept. Report No.: If applicable, fill in Street/Sidewalk Conditions: Check one Weather Conditions: Check one II. Member Property Damage Items Damaged: Location of damage on vehicle (i.e. left front, rear, etc.) Age of Item(s) Damaged: Years old VIN Number: VIN number Make of Vehicle/Mobile Equipment: Make of equipment Year: Year Model: Model License Number(s): License plate number(s) on vehicle/equipment involved III. Member Description of Accident Detailed description of the accident and how it occurred. IV. Type of Accident Check one of the options: Slips, Trips, Falls; Property; Police Professional Liability; Automobile Liability; Employment Liability; Other/Please Explain. V. Claimant Accident/Injury Information (For non-member claim injury information) Name: Name of non-member claimant Sex: Male or female Age/D.O.B.: Age or date of birth Business Phone: If applicable Home Phone: Contact number Address: Address of Claimant

of 9 Nature of Injury/Part of Body: Describe where claimant was injured What Was Injured Person Doing: Describe what the claimant was doing when injured Where Taken: Where was the claimant taken after injury VI. Claimant Automobile Information (For non-member claim automobile information.) Owner of Other Vehicle: Name Age: Age of owner Address: Address of owner City: City of owner State: State of owner Zip: Zip code of owner Phone: Contact phone for owner Driver, if Other Than Owner: Name of driver, unless it is the same as the owner Age: Age of driver Address: Address of driver City: City of driver State: State of driver Zip: Zip code of driver Phone: Contact phone for driver Make of Vehicle: Make Year: Year Model: Model License No.: License plate number VIN No.: VIN number Area of Damage: Location of damage on vehicle Estimate of Damage: Estimate of damage to claimant vehicle Is Vehicle Insured: Check one Company/Agency Name, Policy No., & Phone No.: Claimant insurance information Where Vehicle Can Be Seen: Location of vehicle for inspection by appraiser and for IRMA information VII. Claimant Non-Auto Property Damage Owner of Property: Owner of property Address: Address of property City: City State: State Zip: Zip Phone: Contact number Describe Damaged Property: Area and type of property damaged (be specific) Location of Property: Location of property damaged Is Property Insured: Check one Company/Agency Name, Policy No., & Phone No.: Claimant insurance information

of 9 VIII. Witness Information Please list names of all persons who were at the scene of accident and/or actually witnessed loss take place. Use supplemental sheets if necessary. If no witnesses, please skip. IX. Additional Comments Employee s supervisor must fill in any unsafe conditions, unsafe acts, precautions that should have been taken to avoid the accident, possible remedies, etc. The supervisor must discuss loss in detail with the employee. After the discussion, the supervisor must complete the various questions under Additional Comments. Comments: Any additional employee comments or remarks that he/she feels would be important to the investigation of the loss should be included here. If none, leave blank. Supervisor/Department Manager Signature & Date: Supervisor or department head must sign and date the report before being sent to City Hall and IRMA

of 9 INJURIES Form 45: Employers First Report of Injury or Illness Supervisor s Investigation Report Attached are sample copies of the reports for injury or illness, which are to be completed as soon as possible after an injury. It is the employee s responsibility to immediately report any and all incidents, regardless of severity, to the supervisor. The supervisor will then conduct a personal investigation of the accident location, as well as the working conditions at the accident location; question all persons involved, including any witnesses and coworkers, regarding observation of events prior to, during and after the accident; inspect any tools, materials, equipment or vehicles involved in the accident; obtain necessary evidence including photographs, written statements, material samples, etc.; complete all appropriate accident/injury forms in, ink, and return completed forms to the Administrative Assistant within 24 hours of the accidents occurrence. The Administrative Assistant will distribute the report accordingly. Application of this report pertains to any accident where an employee is injured and requires medical treatment. Both the Form 45 and the Supervisor s Investigation Report must be completed and returned to the Administrative Assistant of Public Works for distribution. The injured employee can fill out the Form 45, but it is the supervisor s responsibility to review it for clarity and completion. The supervisor must fill out the Supervisor s Investigation Report. How to Complete Non-Workers Compensation Accident Report Forms Line A Illinois Unemployment Compensation Number: Leave blank Date of Report: Date of injury/illness Case or File Number: Leave blank Line B Employer s Name: The City of Lake Forest Employer s Fein Number: Leave blank Is This a Lost Workday Case: Check one Line C Doing Business Under the Name of: The City of Lake Forest City, State, Zip: Lake Forest, IL 60045 Line D Mailing Address: 800 N. Field Drive City, State, Zip: Lake Forest, IL 60045 Line E Employee Location if Different From Mailing Address: Office location

of 9 Line F Nature of Business or Service: Municipality SIC Code: Leave blank Total Number of Employees at the Location Where Illness or Injury Occurred: Number of employees onsite Line G Name of Worker s Compen. Insurance Carrier: IRMA Policy Number: Leave blank Self Insured: Check yes County Where Injury Occurred: County Line H Employee s Name: Employee name Social Security Number: Employee social security number Line I Line J Home Address: Employee home address City, State, Zip: City, state, zip of employee Male/Female: Check one Married/Single/Widow(er)/Divorced: Check one Birth Date: Employee date of birth Number of Dependent Children Under 18 at Time of Injury or Illness: Number of employee s dependent children Line K Date and Time of Injury of Exposure: Date and time Employee s Average Weekly Earnings: Salary Last Day Employee Worked: Date Line L Job Title or Occupation: Title Department Normally Assigned: Section Line M Address of Location Where Injury or Exposure Occurred: Address of injury location City, State, Zip: City, state, zip of injury location Line N Did the Employee Die as a Result of the Injury or Illness: Check one Employee Died as a Result of the Injury or Illness: Date, if applies

of 9 Line O Was the Injury or Exposure on the Employer s Premises: Check one Did this Incident Result in: Check if applies Was Employee Given Industrial Commission Handbook: Leave blank Line P Nature of the Injury: What kind of injury Line Q Part of the Body Affected: What part of the body was injured (be specific) Line R What Task was Employee Performing When Illness Occurred: Description of work Line S Object or Substance Responsible for Injury or Illness (Source): Did an item cause the injury? If so, what was it? Line T How Did Accident or Illness Occur (Type): Description of accident Line U What Hazardous Conditions, Methods, or Lack of Protective Devices Contributed: List anything that applies Line V What Unsafe Act by a Person Caused or Contributed to the Injury or Illness: List anything that applies Line W Have Medical Services Been Rendered to the Employee: Check one Is or has the Employee Been Hospitalized: Check one Line X Name and Address of Physcian: Name and address of physician employee saw City, State, Zip: City, state, zip of physician employee saw Line Y Name and Address of Hospital: Name and address of hospital, if applicable City, State, Zip: City, state, zip of hospital, if applicable Line Z Report Prepared By: Signature of employee that filled out the report Signature: Report must be signed before it is turned in Title and Telephone Number: Title and telephone number of employee that filled out the report

of 9 How to Complete Supervisor s Investigation Report Forms Name of IRMA Member (Municipality): The City of Lake Forest Date & Time of Accident: Date and time accident occurred Date Injured Person Reported Accident: When it was reported to the supervisor To Whom Reported: Who was notified of the accident Location of Accident: Name or number of building, address, etc. Name of Injured Employee/Phone Number: Name and number of employee injured Injured Employee s Department: Employee s section Injured Employee s Job: Title Injured Person Status: Check one Time In Job: Check one Date of Hire: Date Average Number of Hours Worked Per Week: Weekly hours Hourly Rate: Hourly pay rate Describe the Injury: What is injured, to what severity, etc. Describe the Accident: What happened, how it happened, etc. Was Employee Requested to go to a Medical Management Facility for Treatment: Check one If Restricted, is Light Duty Available: Check one Is Employee Still Treating with a Medical Management Facility: Check one If Yes, Name and Address of Treating Doctor: List name and address Did/Will the Injured Person Miss More Than 3 Workdays Due to This Accident: Check one No. of Workdays Injured Person Missed: How many days out of work Date Started Losing Time: First date off of work Any Witness to This Injury/Accident: Check one and list witness name, title, and phone number How Could the Injury/Illness Have Been Prevented: List alternatives Remedy: What action have you taken or do you propose taking to prevent a repeat accident Supervisor: Sign and date before filing with the Administrative Assistant of Public Works

of 9 INCIDENTS Incident Reports Incidents resulting in damage to City vehicles, equipment, or property are classified as either incidents or accidents depending upon two factors: 1. The cost to repair the damage. 2. The potential of the incident to have been a serious accident, even if damages were minimal. Any damage done to vehicles should be appraised by the Fleet Supervisor and any building-related damage should be appraised by the Building Maintenance Supervisor. All other damage appraisals should be estimated by the section supervisor and Safety Committee member. Upon appraisal, any damage to City vehicles, equipment, or property under $400 should be filed on an Incident Report. Any damage to vehicles, equipment, or property over $400 should be filed on a Non-Workers Compensation Accident Report Form. Employees with minor injuries that do not require medical attention (i.e. minor cuts, bruises, soreness, etc.) should notify their supervisor and fill out an Incident Report. This report will be kept on file by the Public Works Department, but will not be filed with IRMA.