Louisiana Tech University Department of Environmental Safety Quarterly Safety Meeting
Topic 2
(318) 257-2120
The Louisiana State Office of Risk Management has now gone to a newer, shorter version of the accident form. All faculty and staff should review the attached information for Safety Topic 2 and sign the bottom portion of the memo for documentation by June 30, 1999.
Quarterly Safety Meetings are required by the Louisiana State Office of Risk Management as well as Louisiana Tech University’s Safety Plan. If you have any questions, please contact me at 257-2120.
Reminder’s:
1. For Louisiana Tech University to be in compliance with the Office of Risk
Management Driver Safety Program, everyone driving a Louisiana Tech vehicle or who uses a personal or rented vehicle for university business must complete the driver safety program. Reimbursement for personal vehicle mileage or rented vehicle cannot be issued to employees who have not successfully completed the driver safety program.
2. The following web page address may be accessed for information on items such as Insurance on Rented/Leased/Private Automobiles, Louisiana Tech University Motor Pool, Check lists for people having completed the Driver’s Safety Training Course and What to do if you have a vehicle accident.:
http://ltadm.latech.edu/vpadmaff/Drivsafe.htm
Every State Vehicle should have an Accident Report Form in the glove compartment. If there is no form in the vehicle or you need help in filling out the form, please contact Mr. Billy J. Adcox in the Environmental/Safety Department by calling 257-2120.
The Accident Report Form is in PDF format (Click Here)
INSTRUCTIONS ON HOW TO COMPLETE THE LOUISIANA STATE DRIVER’S ACCIDENT REPORT FORM # DA 2041
(The "*" marked items are mandatory to be completed) This form must be completed within 48 hours after an automobile accident in a State owned vehicle and/or a rented/leased vehicle being used on State business. The completed form should be returned to Mr. Billy Joe Adcox (Campus Box 22) within the 48 hour time period so that he can forward it to the Office of Risk Management Claims Department. (If you are unable to complete all mandatory items in the time period, please complete as many as possible and submit this report within the 48 hour period.)
* 1. Agency’s Name (example: Office of Risk Management)
* 2. The Name of the Contact Person for the Agency (example: John Doe)
* 3. Phone Number of this Contact Person in #2 (example: area code/000-0000)
* 4. ORM Location Code Number for your Agency (Office of Risk Management #0455)
* 5. State Vehicle Driver’s Name (example: Print-Sam J. Jones)
* 6. State Driver’s Social Security Number (example: 111-11-1111)
* 7. Date of Accident (example: 5-26-98)
* 8. Time of Accident (example: 2:00 p.m.)
* 9. Exact Physical Address of this Accident (example: intersection of Florida Blvd. and Wooddale Blvd., Baton Rouge, LA)
* 10. Description of how this Accident Happened (example: The other driver was stopped for a red light on Florida Blvd. and the State driver struck this vehicle from behind)
* 11. Was State Driver using Seat Belts at the time of Accident? (example: yes or no)
State Owned Vehicle or Rented/Leased Vehicle Used for State Business(If more Space is needed, please use a separate sheet)
* 12. State Vehicle Driver’s Home Physical Address (ex.: 100 Avenue A, Baton Rouge, LA. 70804)
* 13. State Vehicle Driver’s Home Phone No. (ex.: area code/000-0000)
* 14. State Vehicle Driver’s Work Phone No. (ex.: area code/000-0000)
* 15. State Vehicle Driver’s License No. (ex.: LA 0011111111)
16. Age of State Driver (ex.: 24)
17. Sex of State Driver (ex.: male or female)
* 18. Full Name of Vehicle Registered Owner and address (ex.: Office of Risk Management, 626 North 4th St., Baton Rouge, LA. 70804)
* 19. Year of Vehicle (example: 1998)
* 20. Make of Vehicle (example: Ford)
* 21. Model of Vehicle (example: Crown Victoria)
* 22. Body Type (example: 4 door or 4 x 4)
* 23. Vehicle License No./Equipment No./VIN (ex.: PP100000/ 123-890/ 2FALP81W5TX156000)
* 24A. Where can the vehicle be seen for inspection (ex.: 100 Oak St., Alton, LA)
* 24B. Describe damages (ex.: Right Front fender and grill)
OTHER VEHICLE INFORMATION(If you need more space, please use a separate sheet)
* 25. Other Vehicle Driver’s Name: (ex.: Henry J. Smith)
26. Other Vehicle Driver’s Social Security Number (ex.: 000-00-0000)
27. Other Vehicle Driver’s License Number (ex.: 002222222)
28. Other Vehicle Driver’s Age (example: 35)
29. Other Vehicle Driver’s Sex (example: male or female)
* 30. Other Vehicle Driver’s Address (street # city, state & zip code)
* 31. Other Vehicle Driver’s Home Phone # (ex.: area code/123-4567)
* 32. Other Vehicle Driver’s Work Phone # (ex.: area code/890-9090)
* 33. Vehicle Owner’s Name and Address (if different from other driver’s name)
* 34. Year of Vehicle (example: 1997)
* 35. Make of Vehicle (example: Chevrolet)
* 36. Model of Vehicle (example: Caprice)
* 37. Body Type of Vehicle (example: 4 Door)
38. License #, equipment # or VIN of Vehicle (ex.: BBB 123, 23-890 or 1F09FGH90RTF123456)
* 39. Where can the Vehicle be seen? (ex.: 123 19th St., Baton Rouge, LA 70806)
* 40. Other Vehicle Insurance Co. (example: State Farm Ins. Co.)
* 41. Policy Number (example: 123-456)
* 42. Describe Damage(s) to Vehicle (ex.: right front fender and grill)
43. Estimate Amount (example: $2500.00)
INJURED
(If you need more space, please use a separate sheet)
* 44. Name and Address of Injured Person (ex.: John Smith, 10 South St., Baton Rouge, LA 70804)
* 45. Phone Number (example: area code/000-0000)
* 46. "Ped" for Pedestrian (ex.: If a pedestrian was hit by vehicle, then place a check mark in this box)
* 47. "Ins. Veh." for Insured Vehicle (ex.: If the driver and/or the passenger was injured in the State/Insured Vehicle then place a check mark in this box)
* 48. "Other Veh." for Other Vehicle (ex.: If the driver and/or passenger in the other vehicle was injured then place a check mark in this box)
* 49. Police Investigation ( ex.: Did the police investigate? Type of Report: Sheriff, City or State)
Witnesses or Passengers
(If you need more space, please use a separate sheet)
* 50. Name and Address (example: John Doe, 19th Ave., Baton Rouge, LA 70804)
* 51. Witness and/or Passenger in vehicle - (Please check the appropriate box to verify if the witness is an independent individual and not a passenger in either vehicle. If the witness is a passenger in the State or other vehicle, then check the appropriate box to indicate which one.)
* 52. Phone for the witness (with area code)
* 53. Pedestrian, Passenger in State Vehicle or passenger in other vehicle. (If witness is other than mentioned, please explain in the "specify" area.)
* 54. Signature of the State Driver (If employee is unavailable, Supervisor may sign for his employee.)
* 55. State Driver’s immediate Supervisor and his/her phone # (with area code)