Safety/Acciden Safety/Accidentt Pol Po lic ies and P rocedur oce duree s Inciden Incidentt / Accident Accident Repor Repo rt Packet P acket Safe Safe ty Proce dur duree As requi required by com c ompany pany policy e xpects each of the staff, sta ff, regardless regardless of his/her his/her position position wi w ithin our organizat organizatiion, to cooperate in every respect with our our safe s afety ty program. Some Some of the major major points points of our program require that: 1. All injuries and accidents are reported immediately to our dispatch department and to obtain medical aid without delay. 2. Person Pe rsonal al protective equipment, where required, required, must be worn by all al l staff. There will will be no excepti exce ptions ons to this requirement. re quirement. 3. Hazardous cond c onditions itions and other safe s afety ty conce concerns rns must must be reported immediate immediately ly to your your supervisor. s upervisor. 4. The staff sta ff will follow all safe ty rules. rules. Failure Failure to follo fo llow w the rules rules will result in disci d isciplinary plinary action a ction or or removal from staff. Accident Policy 1. When there is a staff member member or a student injured injured your your fi f irst priority prior ity is for them to receiv rece ivee medical medica l help. Apply immediate first aid and if it is serious call 911 for help and continue first aid unit medical support support arrives. 2. Let dispatc dispatch h know know abou a boutt the accident accident and a nd explain the detail deta ils. s. 3. COMPLE COMP LETELEY TELEY fill out out an acc a cciident or incident report and include the nec essary documentation, documentation, pictures, signatures, witness statements etc. 4. Turn in all your documentation to our di d ispatch department This operating procedure applies to the reporting and investigation of all accidents/incidents that result in:
A work-related injury to any Netcor Transports employee.
Personal injury to Company personnel while on or using Company owned property; or
Damage to Company owned property.
responsible for reporting any injur injur y work-related accident to their their manager/supervisor manager/s upervisor as Employees are responsible soon as possible. possible. All acci acc idents/incidents must be re ported by no later later than the e nd of the employee employee’s ’s regular work shift. possiblee , the acci a ccident dent scene sc ene should be preserved prese rved and disturbance disturbance of any physical physical Accid Acc idee nt Scene -- When possibl evidence evidence should be be prevented preve nted until t he arriv ar rival al of law enforcement. Unless necessary neces sary to prevent further damage or injury, injury, clean up or repair re pair activities should commence commence onl on ly after afte r all pert pert inent information information has been col c olllected. ecte d.
Vehicular Accident Report Drivers Must complete this form befor fore leavi aving the acc accident Scene Date: Driver: Unit #: Year Location of Accident: Closest Intersection: Netcor Vehicle Damage:
State:
Netcor Transports Information Time: Lic #: Vin# Make
Signal Light (Red, Yellow, Green) Road Cond. (Dry, Snow, wet, Icy, etc.) Wheather Cond.( Sunny, Rain, Fog etc.)
DOB: SS#: Veh towed?
Speed of Netcor Vehicle: Speed of Vehicle # 1: Day Cond. (Day, Dusk, Night,etc.) Other Driver (Vehicle#1)
Driver's Name: Address: Home Phone: ( ) Vehicle Owner's Name: Address: Home Phone: ( ) Year: Describe Vehicle Damage:
Make:
DL#: State: City: Zip: Work Ph: ( ) Licence Plate: City: Zip: Work Ph: ( ) Model: Towed? Odometer:
Insurance Carrier: Carrier Address:
Policy#: Phone:
Name of Passenger #1: Address: Name of Passenger #2: Address:
Phone: Phone: Police Information
Office Name: Police Department: if Yes What are the Charges?
Badge #: Report# Was Anyone Cited of Arrested? Witness information
Witness #1 Name:
Phone: (
)
Witness #2 Name:
Phone: (
)
Witness #3 Name:
Phone: (
)
Page 1 of 2
Passengers of Netcor Transports Vehicle Phone: ( City:
Name: Address:
)
State:
Name: Address:
Phone: ( City:
)
State:
Name: Address:
Phone: ( City:
)
State:
Injuries Name: Address: Injury (describe):
Age:
Name: Address: Injury (describe):
Age:
Name: Address: Injury (describe):
Age:
Sex:
Sex:
Vehicle: City: Which hospital:
State
Vehicle: City: Which hospital:
State
Sex:
Vehicle: City: Which hospital: Accident Description
State
Explain in your own words what happened (be Thorough):
Diagram of Inccident Draw a Diagram of the inccident. Be sure to show the position of all vehicles and pedestrians the point of collission, the path of vehicles after af ter collision, stop signs, traffic signals, and the names of streets, roads etc.
Netcor Unit: Other Veh:
Front Front
Accident Photos Back Sides Full Scene Back Sides Driver signature
Driver signature:
Date: Page 2 of 2
Circle all Completed
Non No n Ve Ve hicula hicula r Inc Inc ident ident / Accident Repor Re portt Date of Inci dent/Accident: ___ __________________________ Empl Empl oyee oyee Name: ____ ______________________________ _________________________________ ___ Client name name : ____ ________________________
Contact Nu mber:_____ mber:_____ _____________________
Witnesses: ______________________________
Contact Nu mber:______ mber:______ ___________________ ___________________
Date of i ncident ncident re port: port: ____ _______________
Time inci dent was was re ported: ported: ____ ___________
Location Location o f incident: __ ____ ___________________________ ___________________________ _____________________________________ __________________________________________ _____ Cause of incident: _____ ___________________________ _____________________________________________________________ _____________________________________________ ___________
Description of incident: (Be Thorough) _____________________________________________________________ _____________________________________________________________________________________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ _____________________________________________ ________ ______________ ______________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _____________________________________________________________________________________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ Outcome of incident: _______________________________________________________________________ __________________________________ _________________________________________ ____ __________________ _____________________________________________________________________________________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ Injuries Injuries an d damage damage to company pers onnel: onnel: _____________________________________________________________________________________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ Damage Damage to c ompany e quipment: ____ ______ ________________________________________ _______________________________________________________ _______________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ _______________________________________________________________________ __________________________________ ___________________________________________________________ ______________________ Injuries and damage to client: _______________________________________________________________________ __________________________________ ____________________________________________ _______ _______________
The undersigned hereby acknowledges that all information within this brief is, to the best of their ability, true and accurate as was witnessed and observed by the undersigned. Sig nature nature and title title of employee: _____ _________________________ _________________________ Date: Date: __ ___________________________
Supervisor Supervisor sig nature: nature: ____ ___________________________________ ___________________________________ Date: ____ ____________________ _________________________ _____
