State Employee Incident/accident Investigation Form printable pdf download

Employee Post Incident/Accident Analysis (DA 2000)

[Not required for Vehicle Accidents When A Police Report Is Issued]

[This form is NOT for use in reporting a claim. The claim reporting form can be found at:

OFFICE OF RISK MANAGEMENT

UNIT OF RISK ANALYSIS AND LOSS PREVENTION

STATE EMPLOYEE INCIDENT/ACCIDENT INVESTIGATION FORM

Worker’s Compensation Claims—For Agency Use Only

(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

This form is prepared for internal use only and is prepared in

FORM DA 2000

Page 1 of 2

REVISED 07/2011

anticipation of litigation.

State Employee Incident/accident Investigation Form