REPORT OF INCIDENT. Type of Accident (Check all that apply): Public (Property Damage or Personal) Incident
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1 (757) or (888) REPORT OF INCIDENT Date: Assigned Work Location: Type of Work: Administrative Professional Management Technical Maintenance Other Involved MANCON Employee s Name and ID#: Type of Accident (Check all that apply): Automobile Accident Building or Facilities Employee Personal Injury Equipment Damage Public (Property Damage or Personal) Incident Other ACCIDENT DETAILS: 1. Date of Incident: Time Incident Occurred: Time Work Shift Started: Date Reported: 2. Incident Physical Address: Details regarding the incident at the site: 3. Description of Incident (Include all details: what happened, who was doing what at the time of the incident, what safety equipment is required for the task, what safety equipment was used for the task, what possibly caused the accident, etc. Attach additional pages as needed): 4. Automobiles Damaged (complete then proceed to Page 2-3): 5. Injury Sustained (complete then proceed to Page 4): 6. Equipment Involved/Damaged (complete then proceed to Page 5): 7. Property Involved/Damage (complete then proceed to Page 5): 8. Cause of Accident (Be Specific): 9. Supervisor s Name/Contact information: 10. Describe possible causes for incident: 11. Describe Physical Evidence at Scene of the Incident (Dropped boxes, Broke equipment, etc.): 12. Initial and provide Date/Time the Incident was called into MANCON Corporate. Who was notified at Corporate? Date/Time Called/ ed In: Site Supervisor s Signature/Date: Human Resources Signature/Date notified: Date HR Received: Page 1 of 5
2 AUTOMOBILE ACCIDENT REPORT Make copies for completion for each MANCON person/vehicle involved. MANCON Driver: DOB: Male/Female: MANCON Driver License information: MANCON Driver Address: MANCON Location and Name Vehicle is assigned to: Purpose for use of Vehicle: Year: Make: Model: VIN: Vehicle License Plate: Location of MANCON Vehicle after Accident: Vehicle Garaged at: (757) or (888) Passenger 1 in MANCON Vehicle: Passenger 2 in MANCON Vehicle: Passenger 3 in MANCON Vehicle: Using the diagrams and lines below, draw and describe the accident and damage to MANCON Vehicle. Page 2 of 5
3 AUTOMOBILE ACCIDENT REPORT Make copies for completion for each NON-MANCON person/vehicle involved. Name of the Other Driver: Other Driver License information: Address: Insurance Company: Insurance Address: Owner of Other Vehicle: License Plate: Year: Make: Model: Other Identifying Features: (757) or (888) Passenger 1 in MANCON Vehicle: Passenger 2 in MANCON Vehicle: Passenger 3 in MANCON Vehicle: If the Police were contacted, provide the officer s name and report number (also attach a copy of the accident report filed). Using the diagrams and lines below, draw and describe the accident and damage to other Vehicle. Page 3 of 5
4 INJURY INFORMATION Make copies for completion for each person injured. Injured Name: Phone Address Job Title Department Date of Birth: Female/Male (757) or (888) First Aid Provided on Site? If Transported Off-Site, How? Employee (Choose one): Remained at work Returned to Work at Did not return to work Employer/Contact Name/Phone (if not MANCON) Employer Address and FRONT SIDE BACK SIDE Indicate the area(s) injured using the graphics above for the front and back side. Description lines are provided for your convenience. Page 4 of 5
5 Owner of Equipment or Property: Address of Owner: Contact Name/ (757) or (888) EQUIPMENT AND/OR PROPERTY DAMAGE Make copies for completion for each piece of equipment and/or property damaged. Insurance Company: Insurance Address: If the Police were contacted, provide the officer s name and report number (also attach a copy of the accident report filed). Using the boxes above, drawn the incident/damage occurred. Description lines are provided below for a detailed description of the incident and the damage that occurred. Attach photos or other documentation of the damaged equipment/property. EQUIPMENT DAMAGE PROPERTY DAMAGE Page 5 of 5
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