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Accident Type Motor Vehicle Accident On the Job Injury Name of employee involved in accident Job Title Location of accident (detailed address/location) Date/Hour of accident Length of time in current job Time at work on accident date Regular Duties Y / N Describe the accident: (Describe what took place or what caused you to make the investigation.) Why did it happen? (Get all the facts by studying the job and situation involved.) What should be done to prevent future occurrences? What have you done thus far? (Take or recommend action, depending upon authority. Was action effective?) Yes No Yes No Supervisor's Signature Date Department Director/Division Manager Date to the Risk Management Division with a copy to Fleet within 2 (two) working days of accident. OGDEN CITY SUPERVISOR'S INVESTIGATION REPORT The immediate supervisor of the employee involved in the accident is to conduct an independent investigation to discover the cause and determine preventability on the part of the City employee. This form is to be completed and forwarded On the Job Injury Unsafe Condition? Unsafe Act? Motor Vehicle Accident Preventable Non Preventable Employee Using Cell Phone? Yes No ---PAGE BREAK---