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City of Hoover Supervisor's Report of Employee Accident INSTRUCTIONS TO SUPERVISOR Inquire about the circumstances surrounding the employee's accident. Based on your inquiry, provide the requested information on this report, sign it, then send this report and other required forms to the City's Risk Management Department. Supervisor's Name: Department: Employee's Employee's Name: Title/Position: Date of Time of Accident: Accident: Location of Accident: Question Yes No # 1 Was the Employee On-Duty When the Accident Occurred? # 2 Was the Employee Injured in the Accident? IMPORTANT NOTE If the Answers to Questions 1 AND 2 were BOTH "Yes", a First Report of Injury Form must be completed and sent to the City's Risk Management Department. If during regular business hours, call the Risk Management Department to report the injury as soon as possible: 444-7574. # 3 Did injuries to Non-Employees Occur? If so, how many were injured? # 4 Did the Accident Involve a Vehicle? IMPORTANT NOTE If the Answer to Question 4 is "No", then skip Questions 5, 6, 7, & 8 and continue with Question # 5 Did Damage Occur to a City Vehicle? If so, provide the vehicle # and vin # Describe # 6 Did Damage Occur to Non-City Vehicles? If so, how many vehicles were damaged? # 7 Did the Vehicular Accident Occur on a Public Roadway? # 8 Did the Vehicular Accident Occur on Private Property? # 9 Did Damage Occur to Non-Vehicular City Property? # 10 Did Damage Occur to Non-Vehicular, Non-City Property? # 11 Were the Police Notified? If so, what is the Case Pelham PD Case #12-016268 ---PAGE BREAK--- This is side one of a two-sided form. Please continue to side two. (Reports received by Risk Management without side two or with side two incomplete will be returned for completion.) City of Hoover Supervisor's Report of Employee Accident Continued #12 As a supervisor, what efforts have been made to determine the cause of the accident and how similar incidents can be prevented? #13 From your investigation, what internal or external factors do you feel may have contributed to this accident? #14 Could the employee have done anything differently to avoid this accident? (If yes, please describe) #15 Were there any guidelines in place relevant to the duties being performed at the time of the accident, and in your opinion, did the employee adhere to them? #16 Are there any other comments you would like to make in reference to this accident? ---PAGE BREAK--- Supervisor's Signature Printed Supervisor's Name Date This is side two of a two-sided form.