ࡱ> _ 2ebjbj pbb\ X$>>>PR>1&,R(zzD$0000000$3L60i0z4`1"""Fz0"0""V +@+ztJRM+ 0v101Y+x77+7+"0017 :  Office of Developmental Disabilities Stabilization and Crisis Unit  SACU Vehicle Incident Report and Supplement to DMV SACU Safety Program: 503-378-5952, ext. 232 Fax: 503-378-5917Employee or volunteer: Complete section A of this form, print it, sign it and give it to your supervisor. In addition, complete the DMV 735-32 and give to your supervior. If required by law (as outlined on the form), also submit the 735-32 to DMV. HYPERLINK "http://www.odot.state.or.us/forms/dmv/32.pdf"Click here for the DMV 735-32 form or visit: HYPERLINK "http://www.odot.state.or.us/forms/dmv/32.pdf"www.odot.state.or.us/forms/dmv/32.pdf Section A  Employee/volunteer report of incidentYour name: FORMTEXT      Date of incident: FORMTEXT       House: FORMTEXT      Date reported to supervisor: FORMTEXT      The incident was in a: FORMCHECKBOX  State vehicle #:E  FORMTEXT       FORMCHECKBOX  Private vehicle FORMCHECKBOX  Rental vehicle Describe the purpose of this trip:  FORMTEXT       Did police respond to the incident?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, police report #: FORMTEXT      I was:  FORMCHECKBOX  injured  FORMCHECKBOX  not injuredIf injured, you must also complete and submit the SDS 0001 Employee Incident/Accident Report available at:  HYPERLINK "http://apps.state.or.us/Forms/Served/se0001.doc" http://apps.state.or.us/Forms/Served/se0001.doc.If injured, indicate which body part(s) were injured:  FORMTEXT       Describe injuries:  FORMTEXT       Describe any recommendations you would make to prevent this or a similar incident from happening in the future:  FORMTEXT        Employee signature:Date: Section B  Supervisor s report of incidentSupervisor name:  FORMTEXT      After reviewing the employee section, you can either: fill in this section by hand and sign it; or open a new DHS 2108 in Word, fill in this section, print and sign it, and attached it to the employee s form. 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