Form DA2000 "State Employee Incident/Accident Analysis Form" - Louisiana

What Is Form DA2000?

This is a legal form that was released by the Louisiana Division of Administration - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Louisiana Division of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DA2000 by clicking the link below or browse more documents and templates provided by the Louisiana Division of Administration.

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Download Form DA2000 "State Employee Incident/Accident Analysis Form" - Louisiana

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STATE EMPLOYEE INCIDENT/ACCIDENT ANALYSIS FORM - DA2000
OFFICE OF RISK MANAGEMENT - UNIT OF RISK ANALYSIS AND LOSS PREVENTION
WORKER’S COMPENSATION – FOR AGENCY USE ONLY
This form is NOT for use in reporting a claim. The claim reporting form can be found at: www.laorm.com
Required for all incidents/accidents except auto accidents, for which a police report serves as the investigation
document.
Keep completed forms on file at the location where the audit/compliance review will occur.
(PLEASE TYPE OR PRINT)
1. AGENCY NAME and LOCATION CODE:________________________________________________________________________
2. ACCIDENT DATE and TIME: ____________________________
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): _____________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
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 WITNESS(ES): _______________________________________________________________________________
13. NAME OF PERSON COMPLETING THIS SECTION OF REPORT: _________________________________________________
14. SIGNATURE: ______________________________________________15. DATE: ____________________________________
FORM DA 2000
Page 1 of 2
REVISED 06/2020
STATE EMPLOYEE INCIDENT/ACCIDENT ANALYSIS FORM - DA2000
OFFICE OF RISK MANAGEMENT - UNIT OF RISK ANALYSIS AND LOSS PREVENTION
WORKER’S COMPENSATION – FOR AGENCY USE ONLY
This form is NOT for use in reporting a claim. The claim reporting form can be found at: www.laorm.com
Required for all incidents/accidents except auto accidents, for which a police report serves as the investigation
document.
Keep completed forms on file at the location where the audit/compliance review will occur.
(PLEASE TYPE OR PRINT)
1. AGENCY NAME and LOCATION CODE:________________________________________________________________________
2. ACCIDENT DATE and TIME: ____________________________
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): _____________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
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 WITNESS(ES): _______________________________________________________________________________
13. NAME OF PERSON COMPLETING THIS SECTION OF REPORT: _________________________________________________
14. SIGNATURE: ______________________________________________15. DATE: ____________________________________
FORM DA 2000
Page 1 of 2
REVISED 06/2020
STATE EMPLOYEE INCIDENT/ACCIDENT INVESTIGATION FORM - DA2000
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)
STATE-OWNED? ______ Y ______N
A. TYPE OF EQUIPMENT: _________________________________________________________________________________
B. IS THERE A JSA FOR EQUIPMENT? ______Y ______N
C. DATE LAST JSA 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 comply with policies/procedures
Failure to use appropriate equipment/technique
Inattentiveness
Inadequate/lack of JSA/standards
Incomplete 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 maintenance
Inadequate training
Wet surface
Worn/broken/defective building components
Broken equipment
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:
FORM DA 2000
Page 2 of 2
REVISED 06/2020
Page of 2