STATE OF CALIFORNIA
ACCIDENT REPORT
This report should be completed
(Other than Motor Vehicle)
and distributed within 48 hours of
the incident. Attach any photos or
diagrams.
STD. 268 (REV. 8-94)
CONFIDENTIAL--ATTORNEY/CLIENT PRIVILEGED DOCUMENT
This is a CONFIDENTIAL report to provide information for use by legal counsel in the event a claim is filed
against the State or its employees. Under no circumstances should information be given to anyone except
authorized state officials.
INCIDENT DATE
LOCATION
(Describe specific location on reverse)
TIME
INJURED PARTY INFORMATION
INJURED PARTY'S NAME
(Last, First, M.I.)
INJURED PARTY'S MAILING ADDRESS
(Street, City, State, Zip)
NATURE AND EXTENT OF APPARENT / CLAIMED INJURY
(Describe incident in detail on reverse)
BIRTH DATE
HOME TELEPHONE NUMBER
( )
DRIVER'S LICENSE NUMBER
WORK TELEPHONE NUMBER
( )
PHOTOGRAPHS TAKEN
YES
NO
IF YES, BY WHOM FIRST AID GIVEN
YES
NO
IF YES, BY WHOM
PROPERTY DAMAGE/LOSS INFORMATION
HOME TELEPHONE NUMBER
PROPERTY OWNER'S NAME
(Last, First, M.I.)
WORK TELEPHONE NUMBER
( )
( )
PROPERTY OWNER'S MAILING ADDRESS
(Street, City, State, Zip)
NATURE AND EXTENT OF DAMAGE / LOSS
(Describe in detail on reverse of this page)
WITNESS INFORMATION
NAME
(Last, First, M.I.)
ADDRESS
(Street, City, State, Zip)
TELEPHONE NUMBER
1.
WORK
( )
DRIVER'S LICENSE NUMBER:
HOME
( )
2.
WORK
( )
DRIVER'S LICENSE NUMBER:
HOME
( )
3.
WORK
( )
DRIVER'S LICENSE NUMBER:
HOME
( )
REPORTING AGENCY NAME
REPORTING EMPLOYEE'S NAME AND TITLE
(Print or Type)
TELEPHONE NUMBER
( )
REPORTING EMPLOYEE'S SIGNATURE
�
REPORTING EMPLOYEE'S SUPERVISOR'S NAME AND TITLE
(Print or Type)
TELEPHONE NUMBER
( )
DISTRIBUTION: ORIGINAL--OFFICE OF THE ATTORNEY GENERAL, TORT UNIT, P. O. BOX 944255, SACRAMENTO, CA 94244-2550 (OR IMS D-8)
COPY--OFFICE OF RISK AND INSURANCE MANAGEMENT, 1325 J STREET, SUITE 1800, SACRAMENTO, CA 95814 (OR IMS D-32)
COPY--RETAINED BY REPORTING AGENCY
