OFFICE OF RISK MANAGEMENT
UNIT OF RISK ANALYSIS AND LOSS PREVENTION
STATE EMPLOYEE INCIDENT/ACCIDENT INVESTIGATION FORM
Worker’s Compensation Claims—To Be Filled Out By Injured Worker’s Employer
(PLEASE TYPE OR PRINT)
1. AGENCY
2. ACCIDENT DATE 3. REPORTING DATE
4. EMPLOYEE NAME (LAST, FIRST)
5. JOB TITLE
6. IMMEDIATE SUPERVISOR
7. DESCRIBE IN DETAIL HOW INCIDENT/ACCIDENT OCCURRED (USE ADDITIONAL SHEET IF NECESSARY)
8. PARISH WHERE OCCURRED 9. PARISH OF DOMICILE
10. WAS MEDICAL TREATMENT REQUIRED Y N
11. EXACT LOCATION WHERE EVENT OCCURRED
12. NAME (S) OF WITNESSES
13. NAME OF PERSON COMPLETING THIS SECTION OF REPORT
14. SIGNATURE 15. DATE
KEEP COMPLETED FORMS ON FILE AT THE LOCATION
WHERE INCIDENT/ACCIDENT OCCURRED
MANAGEMENT SECTION
16. NAME OF PERSON COMPLETING THIS SECTION OF REPORT
17. POSITION/TITLE
18. IS THE PERSON COMPLETING REPORT TRAINED IN ACCIDENT INVESTIGATION ______ Y ______ N
19. WAS EQUIPMENT INVOLVED ______Y ______N (If no, skip to question 20)
A. TYPE OF EQUIPMENT
B. IS THERE A JSA FOR EQUIPMENT ______Y ______ N C. DATE LAST JSO PERFORMED ___________________
20. HAVE SIMILAR ACCIDENT/INCIDENTS OCCURRED ______Y ______N
21. DID INCIDENT INVOLVE SAME INDIVIDUAL _____Y ______N
22. SAME LOCATION ______Y ______N
23. WAS THE SCENE VISITED DURING THE INVESTIGATION ______Y ______N
A. DATE & TIME _____________________________ B. ARE PICTURES AVAILABLE ______Y ______N
C. IF NO, REASON FOR NOT VISITING
ROOT CAUSE ANALYSIS
KEEP COMPLETED FORMS ON FILE AT THE LOCATION
WHERE INCIDENT/ACCIDENT OCCURRED
FORM DA 2000 REVISED 03/2006 Page 1 of 1