Fillable VisitorClientDA3000FillableForm OFFICE OF RISK MANAGEMENT

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VisitorClientDA3000FillableForm OFFICE OF RISK MANAGEMENT

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FORM DA 2000 Page 1 of 2
REVISED 07/2011
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) ____________________________________
____________________________________________________________________________________________________________________________________
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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
This form is prepared for internal use only and is prepared in
anticipation of litigation.
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]
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FORM DA 2000 Page 2 of 2
REVISED 07/2011
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 com ply with policies/ procedures Failure to use appropriate equipm ent/ technique Inattentiveness
Inadequate/ lack of J S A/ standards Incom plete 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 m aintenance Inadequate training Wet surface
Worn/ broken/ defective building com ponents Broken equipm ent 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
This form is prepared for internal use only and is prepared in
anticipation of litigation.
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]
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VisitorClientDA3000FillableForm OFFICE OF RISK MANAGEMENT

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Completed 18 November 2019

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