pinal county risk management supervisor’s vehicle ......complete form and send to risk managementw...
TRANSCRIPT
Pinal County Risk Management Supervisor’s Vehicle/equpiment Investigation Report
Employee Name:
Citizen Name:
Date and Time of Accident/Incident:
Department name: department address: City/town, State & Zip:
Accident Location (street address)
Type of accident/incident: Vehicle/Equip. Non-vehicle/Equip.
Information on vehicle and equipment accidents Intersecting Street or Highway and Mile Post Number: Intersection
Non-intersection
Police Agency and Report Number:
City: Inside
Outside
County:
County Vehicle/Equipment Number:
Vehicle/Equipment involved with: (Check appropriate boxes)
Pedestrian Other vehicle Other (Explain):
Other County Vehicle No. _____ Fixed Object
Event/incident/accident description:
Root cause analysis (Why did it happen?):
Corrective action steps (What should be done?):
Supervisor Title:
Date:
FOR RISK MANAGEMENT PURPOSES ONLY Avoidable/Preventable: YES NO Seat Belts: YES NO Reviewed by:
Title:
Date:
Accident Review Board Recommendations:
Scheduled for hearing with the Accident Review Board
Date:
Complete form and send to Risk Management within 24 hours of the accident/incident Risk Management : 520-866-6236 Fax: 520-866-6477 Email: [email protected]
Step 1-
Start Date -
person(s) responsible -
Completion date-
Start date-
Step 2 -
Person(s) Responsible-
Completion Date-
Revised: 3/19/2019
If additional space needed; please continue on a separate sheet of paper.