Full Text
CORTLAND COUNTY INCIDENT / ACCIDENT REPORT FORM Please complete both sides of this form, legibly & in ink. DEPARTMENT: EMPLOYEE: YES NO NAME OF INVOLVED PERSON: PHONE#: ADDRESS: DATE OF BIRTH: LAST 4 DIGITS SS#: INJURED / NOT INJURED PLEASE LIST ALL WITNESSES (additional space is available on the back of this form if needed): NAME: PHONE PLEASE HAVE ALL WITNESSES COMPLETE A “WITNESS STATEMENT FORM” DATE OF INCIDENT: TIME OF DAY: EXACT LOCATION OF INCIDENT: WHAT HAPPENED: WAS ANY EQUIPMENT / MACHINERY / VEHICLE INVOLVED?: YES NO IF YES, WHAT?: IF COUNTY VEHICLE INVOLVED, PLEASE INDICATE VEHICLE WAS ANOTHER VEHICLE INVOLVED?: YES NO INDICATE WHICH POLICE AGENCY NOTIFIED (if Please attach ACCIDENT INFORMATION EXCHANGE FORM and/or POLICE REPORT if available. SECTION 1: PERSONAL INFO SECTION 2: WITNESS INFO SECTION 3: INCIDENT INFO NOTIFY SAFETY OFFICER IMMEDIATELY: [PHONE REDACTED] [EMAIL REDACTED] ---PAGE BREAK--- Ver. 11/2014 Complete this section only if an INJURY was indicated WAS THERE ANY BLOOD/BODY FLUID EXPOSURE? YES NO IF YES, WHO WAS EXPOSED: CALL SAFETY OFFICER TO SUPPLY APPROPRIATE EXPOSURE PACKET TO ALL EXPOSED INDIVIDUALS IMMEDIATELY [PHONE REDACTED]) NATURE OF INJURY/ILLNESS, AND PART(S) OF THE BODY AFFECTED: WAS MEDICAL TREATMENT PROVIDED?: YES NO BY WHOM?: ADDRESS: WAS THE PERSON TRANSPORTED?: YES NO WHERE?: WAS MEDICAL TREATMENT OR EXAMINATION REFUSED?: YES NO IF REFUSED, PLEASE SIGN THE STATEMENT BELOW AND INDICATE REASONING: AT THIS TIME I AM REFUSING MEDICAL TREATMENT: WHY: WITNESS: REPORT SUBMITTED BY: TITLE: DATE OF REPORT: TIME OF REPORT: AM / PM DEPT. HEAD SIGNATURE VERIFYING CONTACT E-MAIL: DATE OF NOTIFICATION: TIME NOTIFIED: AM / PM SAFETY OFFICER NOTIFIED: BY PHONE / BY EMAIL / IN PERSON DATE OF NOTIFICATION: TIME NOTIFIED: AM / PM ADDITIONAL INFORMATION (attach additional sheets if necessary): Distribute as follows: ORIGINAL = DEPARTMENT HEAD, COPY = INDIVIDUAL SCAN ALL DOCUMENTATION TO: [EMAIL REDACTED] (This will route information to: Safety Officer, Personnel, County Admin & County Attorney) SECTION 4: MEDICAL INFO SECTION 5: NOTIFICATIONS SIGN