Fillable City of Hickory Vehicle/Equipment Accident or Property Damage (City of Hickory)

Fill Online, Printable, Fillable, Blank City of Hickory Vehicle/Equipment Accident or Property Damage (City of Hickory) Form

Use Fill to complete blank online CITY OF HICKORY (NC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

City of Hickory Vehicle/Equipment Accident or Property Damage (City of Hickory)

On average this form takes 13 minutes to complete

The City of Hickory Vehicle/Equipment Accident or Property Damage (City of Hickory) form is 2 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Hickory

BROWSE CITY OF HICKORY (NC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
City of Hickory Vehicle/Equipment Accident or Property Damage Form
To be completed by Coworker Only
**Submit this Report within 24 Hours of Accident/Incident and Return to Supervisor**
Date of Accident: _____________ Time of Accident: ______________
Address of Accident: ___________________________________________
Last Name: __________________________ First Name: ______________________________ MI: ____
Department: ____________________________ Position Title: ____________________________
Immediate Supervisor: __________________________ Supervisor Notified: _______________________
Date and Time Supervisor Notified: _________________________ Witnesses: _____________________
Drug Test?: Yes ____ No ____ Responding Law Enforcement Agency: ____________________________
VIN of City Vehicle: __________________________ VIN of Other Vehicle: _________________________
Serial # ETC of Equipment: _____________________ Other Property Damage: _____________________
I cer
tify that my statements made in this report are true, complete and correct to the best of my
knowledge and belief and are made in good faith. I authorize investigation of all statements made in this
report. I understand that false information may be grounds for dismissal.
Coworker Si
gnature: __________________________________ Date: ____________________________
Description of Accident (when no injury):
Property Damage:
Property Owner Name: __________________________________________________
Address: ______________________________________________________________
Number: _________________________________
Description of Damages/Stolen Property:
Additional Comments:
Reset
✔
City of Hickory Vehicle/Equipment Accident or Property Damage Form
Supervisor Investigation Form
**Submit this Report within 24 Hours of Accident/Incident to Risk/Human Resources**
Did Coworker Return to Work? ____ Yes ____ No If so, Date and Time Returned: __________________
Time Coworker Began Work: ________________ Number of Hours Scheduled to Worked: ___________
Who was responsible for the job site?: ____________________________________________________
Was the coworker interviewed regarding the accident/incident? ____ Yes ____ No
If so, when were they interviewed?: ______________________________________________________
How could this accident/incident been avoided? What, if any, changes will be made?:
Was this corrective action made aware to the coworker? ____ Yes ____ No
Was disciplinary action taken? ____ Yes ____ No If not, please explain:
Other Comments or Information:
I certify that my statements made in this report are true, complete and correct to the best of my
knowledge and belief and are made in good faith. I authorize investigation of all statements made in this
report. I understand that false information may be grounds for dismissal.
Supervisor Signature: ____________________________________ Date: ______________________
Department Head Signature: ___________________________________ Date: __________________
What Personal Protective Equipment or Safety Equipment Was Being Used?
□ Safety Glasses
□ Respirator/Mask
□ Hearing Protection
□ Safety Boots/Shoes
□ Safety Vest
□ Hard Hat
□ Gloves
□ Flagging/Signage/Barricades in Place
□ Chaps
□ Other (specify)
__________________
□ Gas Detector
□ Seat Belt
Was Equipment Used
Correctly?
□ Yes
□ No
✔
✔
✔
Reset
✔
✔
✔
✔
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

City of Hickory VehicleEquipment Accident or Property Damage (City of Hickory)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document