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Accident/Incident (Employees) Post Analysis Reporting Form (Form DA 2000)
Form used for accidents involving EMPLOYEES of the College as part of the Louisiana Office of Risk Management's safety program.
Handle: Document-3691
Owner: Laiche, Karen (User-23, klaich:DocuShare)DS
Wednesday, June 17, 2009 02:32:17 PM CDT
Wednesday, October 4, 2017 03:22:08 PM CDT
Modified By: Laiche, Karen (User-23, klaich:DocuShare)DS
Locked By:
  • FORM DA 2000 REVISED 03/2006 Page of 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. ...
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Adobe Portable Document Format (.pdf) - application/pdf
ORM -Employee Post Incident Accident Analysis DA 2000, 7-14.pdf
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21044
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Appears In: ALL FORMS - Alphabetically Listed by Form Title DELGADO FORMS SAFETY FORMS
Preferred Version: Accident/Incident (Employees) Post Analysis Reporting Form (Form DA 2000)