"Report of Accident/Incident" - Florida

Report of Accident/Incident is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • Released on February 10, 2005;
  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download "Report of Accident/Incident" - Florida

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ADHR 1004.04-3
SD 1305-3
Revised 2/10/05
REPORT OF ACCIDENT/INCIDENT
(Attach eyewitness accounts signed by witness)
Employee’s Name:
_____________________Employee ID Number: ___________
Position / Title:
__________________________________________________
Supervisor’s Name:
__________________________________________________
Date and Time of Accident:
____________________________________________
Date and Time Reported: ________________________________
Person to whom the accident was reported: _______________________________
Task being performed when accident occurred:
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Witnesses:
(names and phone numbers)
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Describe how the accident occurred:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________
Injuries Sustained:
________________________________________________________________________
________________________________________________________________________
________________________________________________________
What could have been done to prevent accidents of this type?
________________________________________________________________________
________________________________________________________________________
________________________________________________________
If injury occurred due to a safety hazard, what has been done to eliminate the hazard?
________________________________________________________________________
________________________________________________________________________
________________________________________________________
If the injury involved a vehicle, was the employee performing his/her job duties at the
time of the accident? Yes ___ No ___ If no, please explain.
(Attach police report if
available)
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Page 1 of 2
ADHR 1004.04-3
SD 1305-3
Revised 2/10/05
REPORT OF ACCIDENT/INCIDENT
(Attach eyewitness accounts signed by witness)
Employee’s Name:
_____________________Employee ID Number: ___________
Position / Title:
__________________________________________________
Supervisor’s Name:
__________________________________________________
Date and Time of Accident:
____________________________________________
Date and Time Reported: ________________________________
Person to whom the accident was reported: _______________________________
Task being performed when accident occurred:
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Witnesses:
(names and phone numbers)
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Describe how the accident occurred:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________
Injuries Sustained:
________________________________________________________________________
________________________________________________________________________
________________________________________________________
What could have been done to prevent accidents of this type?
________________________________________________________________________
________________________________________________________________________
________________________________________________________
If injury occurred due to a safety hazard, what has been done to eliminate the hazard?
________________________________________________________________________
________________________________________________________________________
________________________________________________________
If the injury involved a vehicle, was the employee performing his/her job duties at the
time of the accident? Yes ___ No ___ If no, please explain.
(Attach police report if
available)
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Page 1 of 2
ADHR 1004.04-3
SD 1305-3
Revised 2/10/05
Was the employee determined to be at fault for this auto accident? Yes ___ No___
Was the employee wearing a seatbelt? Yes ____ No ____
Is the employee required to use any safety equipment? Yes ___ No ___
Was he/she using it at the time of the accident? Yes ___ No ___
Were there any signs of drug or alcohol use by the employee? Yes ___ No ___
Did this injury result from exposure to a contagious disease? Yes ___ No ___ If yes,
please provide details.
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Do you agree with the description of the accident on the First Report of Injury or
Illness? Yes ___ No ___ If no, please explain.
________________________________________________________________________
_____________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________
Is the employee dually employed? Yes ___ No ___If yes, where?
Supervisor:
_____________________________________ Date: _____________
(Print Name)
Employee: _______________________________________ Date: _____________
(Signature)
By signing this document, the employee attests that the information contained herein is
true and accurate to the best of the employee’s knowledge.
cc:
Bureau of Human Resources, WC Human Resources Technician III
Safety Specialist
Human Resources Liaison
Office Safety Committee Chairperson
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