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Accident/Incident (Visitor/Client) Post Analysis Reporting Form (Form DA 3000)
Form used for accidents involving VISITORS to the College as part of the Louisiana Office of Risk Management's safety program.
Handle: Document-3688
Owner: Laiche, Karen (User-23, klaich:DocuShare)DS
Wednesday, June 17, 2009 02:19:30 PM CDT
Tuesday, May 21, 2013 08:17:58 AM CDT
Modified By: Laiche, Karen (User-23, klaich:DocuShare)DS
Locked By:
  • FORM DA 3000 Effective 03-2007 Page of OFFICE OF RISK MANAGEMENT UNIT OF RISK ANALYSIS AND LOSS PREVENTION VISITOR/CLIENT ACCIDENT REPORTING FORM General Liability Claims – For Agency Use Only KEEP COMPLETED FORMS ON FILE AT THE LOCATION WHERE INCIDENT/ACCIDENT OCCURRED (PLEASE TYPE OR PRINT) 1. AGENCY NAME and LOCATION CODE 2. DATE and TIME of ACCIDENT 3. VISITOR/CLIENT NAME 4. VISITOR/CLIENT ADDRESS 5. CLAIMANT’S TELEPHONE # 6. CLAIMANT DETAIL DESCRIPTION OF HOW ACCIDENT OCCURRED 7. DID THE EMPLOYEE ... IF APPLICABLE, WAS THIS DONE Y____ N_____ 20. WAS THE CLAIMANT AUTHORIZED TO BE IN THIS AREA ___Y ___N 21. DID ANY EMPLOYEE OBSERVE ANYTHING BEFORE/AFTER THAT IS REVELANT TO THE ACCIDENT ___Y ___N IF YES, WAS A STATEMENT OBTAINED AND ...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
ORM - Visitor Client Post Incident Accident Analysis DA 3000 7-11.pdf
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71323
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Appears In: ALL FORMS - Alphabetically Listed by Form Title DELGADO FORMS SAFETY FORMS
Preferred Version: Accident Reporting Form (Form ORM 3000)