Cdot Form 777 - Employee Incident Statement - Colorado Department Of Transportation

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COLORADO DEPARTMENT OF TRANSPORTATION
EMPLOYEE INCIDENT ST ATEMENT
TYPE OF EVENT:
INJURY ☐
DAM AGE TO CITIZEN ☐
VEHICLE DAMAGE ☐ PROPERTY LOSS/DAM AGE ☐
OTHER ☐
This form must be completed and signed by the employee reporting the injury/illness or damages. Return to your supervisor within
ONE day of the incident
.
DATE OF INCIDENT:
DATE INCIDENT WAS REPORTED:
Last 4 of SSN:
Region/Section:
Employee Name:
Street Address :
City, State, Zip:
Supervisor’s Phone #:
Supervisor Reported to:
Exact Time
and Location
of Incident:
Description of
Incident
(What
happened?)
Cause of
Incident
(What caused
it to happen?)
PERSONAL PROTECTIVE EQUIPMENT
Y ☐
N ☐
Was the approved (Per PD 80.1) Personal Protective Equipment (PPE) issued?
Y ☐
N ☐
Was the approved PPE in use at the time of the incident?
If NO, please explain: ______________________________________________________________________
Check all PPE used at the time of the incident: ☐ Hard Hat ☐ Eye Protection ☐ Hearing Protection
☐ Face Protection
☐ Traffic Vest
☐Hi-Viz Apparel
☐Gloves
☐ Boots
☐ Winter wear
☐ Task-Specific PPE (i.e.,
Coveralls
respirator, winter tread wear, chain saw chaps, cut -resistant gloves, etc.).
WORK RELATED INJURIES/ILLNESS(S)
Pursuant to Rule 8-2 (A) of the Colorado Workers’ Compensation Rules of Procedure, CDOT hereby
designates the authorized treating providers (ATP’s) listed on the ATP roster provided. The ATP list
effective date is: ______________.
I hereby acknowledge receipt of this ATP list and state that I choose to obtain medical treatment from
the following provider:
ATP Provider Name: _____________________________
☐ I acknowledge receipt of the ATP list and I am refusing medical treatment at this time.
Y ☐
N ☐
INCIDENT WITNESSES
SIGNATURE
Date:
Employee Signature:
Previous editions are obsolete & may not be used
CDOT Form #777
12/15

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