Laserfiche WebLink
ACCIDENT/INCIDENT DETERMINATION FORM <br /> Employee Name: Employee Job Title: Today's Date: <br /> Day of Event: Day of the week: Time of event: <br /> Am <br /> Pm <br /> FTA Drug&Alcohol Testing FTA Drug&Alcohol Testing <br /> Criteria Met Criteria NOT Met <br /> PREVENTABLE PREVENTABLE NON-PREVENTABLE <br /> Two(2) Points Assessed One(1) Point Assessed No Points Assessed <br /> ❑ Fatality:an individual dies The employee did not demonstrate <br /> enough control over the situation or <br /> could have taken more defensive <br /> action(s)to prevent: <br /> ❑Personal injury that is not serious <br /> One or more non-serious injury <br /> Damage to the facilities equipment or <br /> infrastructure that disrupts the <br /> operations of the agency <br /> ❑Other(meets criteria above of lack of <br /> control or defensive action) <br /> Two(2) Points Assessed Half(1/2) Point Assessed No Points Assessed <br /> ❑ An individual suffers serious bodily An occurrence that does not disrupt <br /> injury and receives medical operations and the employee's actions <br /> treatment away from the scene of directly or indirectly contributed to the <br /> the accident.(Individual refers to event. <br /> employees,pedestrians,passenger ❑Preventable passenger falls <br /> or person in other vehicle(s) ❑Violation of policy or procedure <br /> ❑ A vehicle incurs disabling damages ❑Improper use of vehicle(equipment- <br /> as a result of the event and a vehicle doors/lift/ramp/etc.) <br /> is transported away from the scene ❑ Other(explain): <br /> by a tow truck or other vehicle <br /> Retraining(Involvement in any preventable ❑Retraining(Involvement in any preventable <br /> accident/incident with points assessed, accident/incident with points assessed,which does <br /> which does not result in termination,will result not result in termination,will result in the <br /> in the employee being retrained in the employee being retrained in the deficient area. <br /> deficient area.List courses or type of <br /> re-training required: List courses or type of re-training required: <br /> Investigator's Signature: Date: <br /> • <br /> 106 <br />