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LIST ANY SAFETY PRACTICES THAT CAN BE PERFORMED TO HELP PREVENT REOCCURRENCE IN DEPARTMENT. Who Completed IT & WHO Affected in Department By these Corrective ActionsDATE COMPLETED FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Print Supervisor/Investigator Name  FORMTEXT      Supervisor Signature Investigation Date  FORMTEXT       Date Notified of Accident  FORMTEXT        Department Accident Audit Checklist: (Complete within 48 hours or request 5 days extension before sending to Risk Management.) Check Basic Procedures & Risk Management Standards Completed  FORMCHECKBOX Y  FORMCHECKBOX N Sent accident report to Risk Management within 24 hours.  FORMCHECKBOX Y  FORMCHECKBOX N Completed investigation  FORMCHECKBOX Y  FORMCHECKBOX N Completed corrective actions.  FORMCHECKBOX Y  FORMCHECKBOX N Sent copy of any employee medical restrictions to Risk Management and used light duty program to comply with restrictions from doctor if applicable.  FORMCHECKBOX Y  FORMCHECKBOX N Used designated doctor  Doctors Care.  FORMCHECKBOX Y  FORMCHECKBOX N  FORMCHECKBOX N/A Completed post-vehicle accident drug screen within 24 hours. Date:  FORMTEXT        FORMCHECKBOX Y  FORMCHECKBOX N  FORMCHECKBOX N/A Completed Driver alcohol screen within 2 hours. Date:  FORMTEXT        FORMCHECKBOX Y  FORMCHECKBOX N  FORMCHECKBOX N/A Took vehicle to or called Fleet Service for damage inspection within 48 hours. Supervisor Self Compliance Audit and Risk Management Checklist 1. Accident Date: FORMTEXT      2. Accident Time:  FORMTEXT        FORMCHECKBOX  AM  FORMCHECKBOX  PM3. Employee and/or Claimant Name:  F1@AB6^Ikdk$$Ifl4\LP">+ B~ p   0+4 laf4p  h$IfN $&(2468LNPZ\bdxz|нЪЗЄq$j phPI5CJOJQJU$johPI5CJOJQJU$johPI5CJOJQJU$jmhPI5CJOJQJU$jFmhPI5CJOJQJUhPI5CJOJQJ)jhPI5CJOJQJUmHnHujhPI5CJOJQJU)^`bUIIII h$Ifkd2n$$Ifl4\LP">+ B~ p   0+4 laf4p .VUIIII h$Ifkdp$$Ifl4\LP">+ B~ p   0+4 laf4p  *,.0DFHRTZ\prt~ݽݽݽݽݽݽݽݽqݽݽ^$jthPI5CJOJQJU$j3thPI5CJOJQJU$jshPI5CJOJQJU$jZrhPI5CJOJQJU$jqhPI5CJOJQJUhPI5CJOJQJ)jhPI5CJOJQJUmHnHujhPI5CJOJQJU$jnqhPI5CJOJQJU$VXZUIIII h$Ifkdr$$Ifl4\LP">+ B~ p   0+4 laf4p 024>@Bl ŵŢʼnzm^ŵK$jvhPI5CJOJQJUjhPI5UmHnHujvhPI5U hPI5jhPI5UhPI)jhPI5CJOJQJUmHnHu$j vhPI5CJOJQJUjhPI5CJOJQJUhPI5CJOJQJhPI5CJOJQJ)jhPI5CJOJQJUmHnHujhPI5CJOJQJUBlUIICIII$If h$Ifkdu$$Ifl4\LP">+ B~ p   0+4 laf4p jLVLLF: T(^T` $ ha$kdnw$$Ifl4 \LN P">+  ~ p0+4 laf4 h$IfTfjLM[\]abpqr45CDEIJX˾˱ˤ˗ˊ}pj {hPI5UjzhPI5UjzhPI5UjyhPI5Uj+yhPI5UjxhPI5Uj;xhPI5U hPI5jhPI5UhPICJaJhPI5CJ\aJhPI5CJ aJhPI5CJaJ*4`T$If$^`a$ ~ (^~ ` #(~ (^~ ` ~ #((^` T (^` T(^T` XYZ *,.vij~hPI5UjhPI5UmHnHujS~hPI5Uj}hPI5Ujc}hPI5Uj|hPI5U!jhPI5CJUmHnHujs|hPI5Uj{hPI5U hPI5jhPI5Uj{hPI5U)$&( 68:`j/hPI5U hPI5aJjhPI5Uj?hPI5UjǀhPI5UjhPI5UmHnHujAhPI5UjhPI5UjQhPI5UjhPI5U hPI5,TVrtv .02BD`bdջչլ՟ՒՅ~ hPI5\jņhPI5UjMhPI5UjׅhPI5UjɄhPI5UUjhPI5UjhPI5U hPI5jhPI5UmHnHujhPI5UjhPI5U-"$yss$Ifkd $$IflF'N   06    4 la<ORMTEXT       4. Date Notice of Accident Received by Supervisor or Supervisor-in-charge:  FORMTEXT      Within 24 Hrs?  FORMCHECKBOX  Y  FORMCHECKBOX  N5. Investigation of All Causes Determined?  FORMCHECKBOX  Y  FORMCHECKBOX  N Describe causes.  FORMTEXT       6. Confirm actual actions that were taken!!!!!! What was done? What is the Status? Who will benefit from the changes and how will they prevent similar accidents in your department?  FORMTEXT        7. Dates Completed?  FORMTEXT       8. Designated Physician  Doctors Care Used?  FORMCHECKBOX  Yes  FORMCHECKBOX No  If not used, why not?  FORMTEXT       9. Light Duty Used:  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Describe light duty assignment.  FORMTEXT       11. Department Head, Assistant County Administrator, or County Administrator Signature:  12. 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