Fillable DA2000 Employee Fillable Form (Baton Rouge Community College)

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DA2000 Employee Fillable Form (Baton Rouge Community College)

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The DA2000 Employee Fillable Form (Baton Rouge Community College) form is 2 pages long and contains:

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  • 18 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Baton Rouge Community College

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Employee Post Incident/Accident Analysis (DA 2000)
[Not required for Vehicle Accidents When A Police Report Is Issued]
[This form is NOT for use in reporting a claim. The claim reporting form can be found at: www.laorm.com]
OFFICE OF RISK MANAGEMENT
UNIT OF RISK ANALYSIS AND LOSS PREVENTION
STATE EMPLOYEE INCIDENT/ACCIDENT INVESTIGATION FORM
Worker’s Compensation Claims—For Agency Use Only
(PLEASE TYPE OR PRINT)
1. AGENCY ______________________________________________________________________________
2. ACCIDENT DATE ________________________ 3. REPORTING DATE ________________________
4. EMPLOYEE NAME (LAST, FIRST) ________________________________________________________
5. JOB TITLE_____________________________________________________________________________
6. IMMEDIATE SUPERVISOR ______________________________________________________________
7. DESCRIBE IN DETAIL HOW INCIDENT/ACCIDENT OCCURRED (USE ADDITIONAL SHEET IF NECESSARY)_____________________________________
8. PARISH WHERE OCCURRED ______________________________________ 9. PARISH OF DOMICILE _______________________________________
10. WAS MEDICAL TREATMENT REQUIRED ________ Y ________ N
11. EXACT LOCATION WHERE EVENT OCCURRED _______________________________________________________________________________________
12. NAME (S) OF WITNESSES ___________________________________________________________________________________________________________
13. NAME OF PERSON COMPLETING THIS SECTION OF REPORT ___________________________________________________________________________
14. SIGNATURE _____________________________________________________________ 15. DATE ____________________________________________
KEEP COMPLETED FORMS ON FILE AT THE LOCATION
WHERE INCIDENT/ACCIDENT OCCURRED
FORM DA 2000
REVISED 07/2011
This form is prepared for internal use only and is prepared in
anticipation of litigation.
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Employee Post Incident/Accident Analysis (DA 2000)
[Not required for Vehicle Accidents When A Police Report Is Issued]
[This form is NOT for use in reporting a claim. The claim reporting form can be found at: www.laorm.com]
MANAGEMENT SECTION
16. NAME OF PERSON COMPLETING THIS SECTION OF REPORT ___________________________________________________________________________
17. POSITION/TITLE ___________________________________________________
18. IS THE PERSON COMPLETING REPORT TRAINED IN ACCIDENT INVESTIGATION ______ Y ______ N
19. WAS EQUIPMENT INVOLVED ______Y ______N (If no, skip to question 20)
A. TYPE OF EQUIPMENT __________________________________________________________________________________________________________
B. IS THERE A JSA FOR EQUIPMENT ______Y ______ N C. DATE LAST JSO PERFORMED ___________________
20. HAVE SIMILAR ACCIDENT/INCIDENTS OCCURRED ______Y ______N
21. DID INCIDENT INVOLVE SAME INDIVIDUAL _____Y ______N
22. SAME LOCATION ______Y ______N
23. WAS THE SCENE VISITED DURING THE INVESTIGATION ______Y ______N
A. DATE & TIME _____________________________ B. ARE PICTURES AVAILABLE ______Y ______N
C. IF NO, REASON FOR NOT VISITING___________________________________________________________________________________________________
ROOT CAUSE ANALYSIS
UNSAFE ACT (PRIMARY): Failure to comply with policies/procedures Failure to use appropriate equipment/technique Inattentiveness
Inadequate/lack of JSA/standards Incomplete or no policies/procedures Inadequate training on policies/procedures Inadequate adherence of
policies/procedures
Other (specify) ______________________________________________________________________________________________________
Detailed explanation of checked box _____________________________________________________________________________________
______________________________________________________________________________________________________
WHY WAS ACT COMMITTED:
UNSAFE CONDITION (PRIMARY): Inappropriate equip/tool Inadequate maintenance Inadequate training Wet surface
Worn/broken/defective building components Broken equipment Inadequate guard Electrical hazard Fire Hazard
Other (specify) ______________________________________________________________________________________________________
Detailed explanation of checked box _____________________________________________________________________________________
___________________________________________________________________________________________________________________
WHY DID CONDITION EXIST:
CONTRIBUTORY FACTORS (IF ANY):
IMMEDIATE ACTION TAKEN TO PREVENT RECURRENCE:
LONG RANGE ACTION TO BE TAKEN:
WHAT ADDITIONAL ASSISTANCE IS NEEDED TO PREVENT RECURRENCE:
KEEP COMPLETED FORMS ON FILE AT THE LOCATION
WHERE INCIDENT/ACCIDENT OCCURRED
FORM DA 2000
REVISED 07/2011
This form is prepared for internal use only and is prepared in
anticipation of litigation.
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DA2000 Employee Fillable Form (Baton Rouge Community College)

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Completed 24 July 2020

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