DCAM/RISK MGMT - FORM 001a (01/2020)
PAGE 2 OF 2
Non-vehicle personal property damage
Describe damaged property incident:
Personal property specifics
Description Brand Type Serial Number
If state vehicle was involved in incident:
Was the vehicle involved in the accident in proper working order? Yes No
If no, explain
Was employee distracted in some way? (Cell phone, food, etc…) Yes No
If yes, explain
Was the employee issued a citation? Yes No If yes, why?
Was weather a factor in the incident? Yes No If yes, explain
If damage to property was done by equipment – gate, door, etc…:
Was damage due to equipment malfunction/breakage? Yes No
Who is responsible for maintenance?
How is it maintained?
Routine maintenance performed? Yes No If so, when?
Maintenance provided by Contact information
What has been done to keep problem from reoccurring?
By signing this form you are attesting the information contained is accurate.
Employee signature Date Risk coordinator signature Date
Employee name printed Coordinator name printed