Fillable STATE OF GEORGIA Liability Incident Report Form (Kennesaw State University)

Fill Online, Printable, Fillable, Blank STATE OF GEORGIA Liability Incident Report Form (Kennesaw State University) Form

Use Fill to complete blank online KENNESAW STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STATE OF GEORGIA Liability Incident Report Form (Kennesaw State University)

On average this form takes 10 minutes to complete

The STATE OF GEORGIA Liability Incident Report Form (Kennesaw State University) form is 2 pages long and contains:

  • 0 signatures
  • 36 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Kennesaw State University

BROWSE KENNESAW STATE UNIVERSITY 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
 
STATE OF GEORGIA
Liability Incident Report Form
If property of others is damaged (or alleged) as a result of the State’s operations, whether negligent or not, report the
claim directly to Risk Management by email riskmanagement@kennesaw.edu or in person Kennesaw Campus, Chastain
Pointe, Suite 109A.
Time is of the essence. Do not delay reporting the claim because you do not have all the information regarding the
accident. Any additional information can be provided at a later date. Use multiple sheets for more than one Claimant.
Accident Information - General Liability
State Agency involved:
Date of the incident:
Incident time:
Incident location:
City and County:
Description of the incident:
Police authorities contacted:
If yes, Accident Report Number:
Claimant Information
Name & address of the Claimant:
Home Telephone No.
Work Telephone No.
Injured party date of birth:
Social Security No.
Injury Information
Brief description of the claimant’s injury:
Fatality: Yes No
What initial treatment was given? By whom?
Was hospital treatment needed? Which hospital?
Witness Information
Were there any witnesses?
If so, please fill out Witness Form
Property Damage to Others Information
Claimant’s property involved:
Where is the property located now?
Damage to Claimant’s property:
Repair estimate:
Your Name: __________________________ Phone Number: __________________________
BOR - Kennesaw State University - Agency # 7246
Revised 11/2018
Department of Environmental Health
& Safety
INCIDENT WITNESS STATEMENT
Instructions: This form should be completed witness to an accident that results in injury or illness. The form should be as
soon as possible (24 hrs) and submitted to the injured employee’s immediate supervisor.
EOSMS 108-3 Incident Witness Statement 02/02/2015 Page 1 of 1
Page1of1
To be completed by accident witness
Injured employee First
Name
Injured employee Last
Name
Witness First Name Witness Last Name
Witness Home address: Tel #
City State Zip Code
Witness Job Title
Witness
Department
Witness Supervisor Name
Supervisor
Tel #
Employment Type
Faculty
Staff
Student
Contractor
Others_________
Employment Category
Regular full time
Regular part time
Seasonal
Temporary
Length of Employment
1-6 mos.
6 mos. – 1 yr.
1 yr. – 5 yrs.
5 yrs. (or more)
Describe the incident
Date of Incident
Time of the
incident
Shift
1
st
2
nd
3
rd
Location of the Incident
(Address)
Specific Location of the incident
(e.g office, mechanical room, shop)
Did the incident involve property
damage?
Yes
No
Was a motor vehicle involved in this incident?
Yes
No
Affected body Part:
Head/face Eye Neck/shoulder Arms/elbow Right Hand Left Hand Wrist/Head Rib
Fingers Chest/lower trunk Hip Back Leg/knee Foot/ankle Toes
Other
________
Describe, step-by-step, how the incident occurred:
What would you recommend to prevent this accident from recurring:
Witness Signature
Date
MOTOR VEHICLE USE PROGRAM
DRIVER NOTIFICATION
RMS101 Form-2
Employees are to use this form to notify their supervisor of activities that may affect their eligiblity to
operate a motor vehicle for state business.
Employee Information
Employee Name
Employee ID
Work Unit
Frequency of driving on state business
Weekly or more often
Infrequently
Reported Activity (Select all that apply)
I received a traffic citation while driving on state business
Date Received
Charge
I was involved in an on-the-job accident while driving on state business
Date of accident
Any injuries? Yes No Any property damage? Yes No
My driver’s license has been (select one)
Suspended Revoked Expired Date of Action
I was charged with the following (select all that apply)
Driving Under the Influence
Driving While Intoxicated Date of Charge
Leaving the Scene of an Accident
Refusal to take a Chemical Test for Intoxication
Aggressive Driving*
Exceeding the Speed Limit by more than 19 mph*
I understand that this notification may affect my eligibility to drive on state business.
I may be required to view a driver safety video and successfully complete a defensive
driving course, and I may be subject to other appropriate action.
__________________________________ ________________________
Signature Date
Revised 11/2018
MOTOR VEHICLE USE PROGRAM
SUPERVISOR’S ACCIDENT FOLLOW-UP CHECKLIST
RMS101 Form-3
Supervisors are to complete this checklist and forward it to the Risk Management Services Division (RMS) within
2 work days of being advised of an on-the-job accident that occurred while driving on state business.
DRIVER INFORMATION
Name Work Unit
Date of Accident Frequency of driving on state business
Weekly or more often
Infrequently
CHECKLIST
Meet with the Driver to discuss the details of the accident.
Did the driver meet the following requirements? Yes No
Requirement Date
Obtain all necessary information at the scene
Call loss into Risk Management immediately-470-578-2599 or 404-558-1572
Respond to any acknowledgements or requests sent by DOAS RMS
Obtain the police report, if reques
ted, and forward to Risk Management
Discuss appropriate corrective action, depending on whether the driver was cited
for the accident.
Recommendation Date
On-line defensive driving course at employee’s expense
View an appropriate driver safety video
No further action warranted
Forward to DOAS Accident Review Panel for the following determinations:
Preventable
Non-Preventable
Additional Recommendations
Forward copy to Human Resources for placement in the employee’s personnel file.
SUPERVISOR INFORMATION
Printed Name Work Unit
Signature
Date
Revised 11/2018
MOTOR VEHICLE USE PROGRAM
DRIVER SAFETY TIPS
RMS101 – Driver Safety Tips
9 Observe Speed Limits and Traffic Laws – Allow sufficient time to reach your destination
without violating speed limits or traffic laws.
9 Drivers License - Employees who drive state or privately owned vehicles on state business
must possess and carry on their person a current valid Operator's or CDL license and must
present it upon request to any authorized person.
9 Insurance - Employees who operate their privately owned vehicles on state business shall carry
proof of financial responsibility at all times that the vehicle is in operation and must present
evidence of current insurance coverage upon request to any authorized person. It is suggested
that all employees driving on state business have a copy of the state’s insurance card and
present that to the police in the event of an accident.
9 Seat Belts – Each driver and front seat passenger in any motor vehicle operated on a street or
highway in this state is required by law to wear a properly adjusted and fastened seat belt.
9 Cargo - Drivers hauling any type of cargo should ensure that the cargo is properly secured, and
that the height of the cargo is such that it shall safely pass under obstructions such as
under/over passes along the intended route before placing the vehicle in motion.
9 Electronic Devices – The use, operation and manipulation of electronic devices such as cellular
phones, Blackberries, or PDAs, by the driver while the vehicle is in motion is strongly
discouraged. Even with “hands free” equipment, conversing on the phone takes attention away
from driving; making it less likely the driver will notice hazardous situations. Employees are
neither required nor expected to use electronic devices for work-related reasons while driving.
9 Backing – Whenever possible, park the vehicle where backing is not required. Know what is
beside and behind the vehicle before beginning to back. Back slowly and check both sides as
well as the rear while backing. Continue to look to the rear until the vehicle has come to a
complete stop.
9 Intersections – When approaching and entering intersections be prepared to avoid crashes that
other drivers may cause. Take precautions to allow for the lack of skill or improper driving habits
of other drivers. Potentially dangerous acts include speeding, improper turn movements, and
failure to yield the right of way.
9 Weather Related Hazards – Rain, snow, fog, sleet or icy pavement increase the hazards of
driving. Slow down and be especially alert when driving in adverse conditions.
9 Passing – When you pass another vehicle, look in all directions, check your blind spots, and use
your signal. As a general rule, only pass one vehicle at a time.
9 Front End Crashes – By maintaining a safe following distance at all times, the driver can
prevent front-end collisions in spite of abrupt or unexpected stops of the vehicle ahead. Observe
the “two second rule” by following the vehicle ahead at a distance that spans at least two
seconds. The following distance should be increased when driving in adverse conditions.
9 Security – State vehicles should be locked whenever they are unoccupied.
9 Engines – The engine of a State vehicle should always be turned off before the driver exits the
vehicle.
Revised 8/2016
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

STATE OF GEORGIA Liability Incident Report Form (Kennesaw State University)

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 18 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document