The referenced Report form is to be used by every department/agency of the City of Baton Rouge and Parish of East Baton Rouge to record any: (1) ACCIDENT involving any City Parish vehicle or piece of equipment that causes damage or injury; (2) Other workplace accident resulting in INJURY OR ILLNESS to a City Parish employee; or (3) SERIOUS INCIDENT—which is an incident or near accident where that is NO DAMAGE OR INJURY, but where significant damage or serious injury could have resulted.

The purpose of this report is to assist the appropriate safety officer in determining the cause of an accident or incident in order to take steps to prevent a recurrence, if possible. There is no intent to find fault with any employee. This report will also be utilized in the reviewing of accidents that are brought before the Accident Review Committee and Accident Appeal Board.

The first section (pages 1-3) is to be fully filled out and signed by the employee involved in the accident/incident. This section simply gives the employee the right and freedom to explain, in his/her own words, what happened and to express his/her opinion as to the cause and how the accident/incident could have been prevented. The details of this section are crucial in the investigation of the accident/incident, if this type of accident/incident is to be avoided in the future. By signing the form the employee is verifying that the information is his or her account of the accident/incident. Even if the employee has someone assist with the form, the employee’s signature verifies the information came from him/her. Please keep in mind that the form should be completed with BOTH the employee and supervisor together.

The last section (page 4) is to be filled out and signed by the employee’s supervisor.

Any employee operating a City Parish vehicle or piece of equipment at the time of an accident/incident; or who is injured on duty; or who causes an on-duty accident/incident or injury shall immediately complete the first section with his/her supervisor present. The supervisor would then complete the last section and submit a copy of the form to the appropriate appointing authority or safety officer. The original should be sent to the Risk Management Division of the Parish Attorney Office for review, assessment and possible recommendations for safety policies.

For questions or additional information you may contact the Risk Management Division at 389-3267, or come by 10500 Coursey Blvd., Suite 201, Baton Rouge, La. 70816 - 2nd floor.