Date of Issue: 02/01/2017 Accident Reporting

Accident Reporting / Investigation

Date of Issue: 02/01/2017 Date of Revision: Original Revision #: 0

ADM-02 Standard Operating Procedure Page 1 of 6

1. POLICY

This policy is for each employee to timely report all accidents and incidents using the City forms to their division directors/supervisors. Supervisors are to investigate and complete all reporting forms for each accident/incident and directors are to review and sign-off to complete the process. All accidents/incidents forms are to be forwarded to the Office of Labor Relations & Risk Management.

2. SCOPE

This SOP shall apply to all City departments/divisions, department directors, supervisors and employees. 3. PURPOSE

The purpose of accident reporting and investigation is to establish a process to report accidents/incidents to meet good business practices and to comply with regulatory and insurance requirements. The purpose of accident reporting and investigation is also to determine the contributory cause(s) of the accident event and to provide a management process to implement operational changes to prevent similar accident events from recurring.

4. RESPONSIBILITIES

Department Directors / Division Directors Department/Division directors are responsible for the implementation of the procedures and review/sign-off of each accident/incident investigation that is investigated by the responsible supervisor. Supervisors Supervisors are responsible for assisting the directors in the implementation of this accident reporting and investigation process. Supervisors will investigate each accident/incident to further recommend preventative proactive practices. Employees Employees are required to comply with reporting all accidents/incidents and completing all accident/incident reports or other process form approved by Risk Management. Risk Management Risk Management will review all accident/incidents reports and follow up or participate in accident investigation when such condition warrants or is requested by Department Director.




5. DEFINITIONS

Accident - An unexpected and undesirable event, a situation that happens when personal injury or property damage occurs.

Accident-Incident Report - A report that needs to be filled out after every accident or incident. This form is available on the City’s intranet under the icon for the Department of Labor Relations and Risk Management. See Appendix A.

Incident - An unexpected event where personal injury or property damage could occur if not investigated and proper corrective actions are not taken.

General Liability claims include all liability claims, other than injuries or damages caused by licensed motor vehicles used on public roads. This includes losses resulting from slip and fall, potholes, civil rights, false arrest, personal injury or injury on recreation equipment, heavy equipment accidents, improper warning in construction areas, etc.

Motor vehicle is considered a vehicle licensed to be used on the roadway and would include but not limited to: motorcycles, passengers’ type vehicles, trucks, buses, and all trailers.

Property Claims include losses to either real or personal property owned or under the care, custody and control of the City. Examples are windstorm, fire, theft, vandalism, etc., to building or contents.

6. MINIMUM CITY ACCIDENT/INCIDENT REPORTING REQUIREMENTS

6.1 Motor Vehicle Accidents

6.1.1 Example of motor vehicle accidents:

a. A City vehicle strikes another vehicle.

b. A City vehicle strikes a private dwelling.

c. An object falls off the truck and strikes a vehicle or pedestrian. 6.1.2 The accident must be reported to the Police Department immediately.

6.1.3 Employee shall immediately, call their Division Director or Supervisor to assist in the reporting and crash investigation.

6.1.4 Notification of such accidents also should be provided to the Risk Manager at 305-460-5528 immediately. Accidents occurring after normal working hours should be reported by voicemail to 305-460-5528 or by e-mail to [email protected].

6.1.5 The initial verbal notification to Risk Management should contain:

a. Name, address and telephone number of claimant;

b. Location of incident;

c. Description of incident;

d. Witness name, address and telephone number.




6.1.6 In the event of serious accidents after normal working hours, such as death or significant injury, please

call the Risk Manager at 305-733-0208 or the Director of Labor Relations and Risk Management at 305-733-0309.

6.1.7 No matter what the circumstances surrounding the accident may be, the employee is never to make an admission of liability to any of the parties involved in the accident.

6.1.8 A City vehicle involved in an accident should not be moved until so directed by the Police Department when they respond to the scene. If the damaged vehicle is obstructing traffic, the driver is obligated under Florida law to move the vehicle and allow for the regular flow of traffic. This should be accomplished only after photographs are taken for documentation. Also, if you have traffic cones, flags, barricades, etc., or have an emergency beacon on your vehicle, you are required to use these to help identify the accident scene.

6.1.9 Employee must complete the accident/incident report that is available online and may be printed by the employee or their supervisor to be filled out. (See Appendix A) The accident/incident report is easily obtained from the City’s intranet under the icon for the Office of Labor Relations and Risk Management. Obtain the accident investigating agency report number, names of all parties involved, their addresses, phone numbers and any witnesses.

6.1.10 If the City vehicle is inoperable or unsafe to drive, employee must notify the Division Director or Supervisor for instructions for designated service for towing.

6.1.11 Employee shall assist the supervisor, as necessary, in completing the accident/incident report. The purpose of the investigation is to determine the cause of the accident to prevent recurrence.

6.1.12 Supervisor’s Responsibility:

a. If at the accident site, assure proper care of injured persons.

b. Assure that proper police agency has been notified and call Risk Management to assist if necessary.

c. Complete accident/incident report. (See Appendix A) Try to maintain all evidence (Take photos of the accident scene, damage, etc.).

d. Assist Risk Management as necessary to prepare reports/investigation.

e. Arrange a drug test for the City employee, if required by City’s Drug and Alcohol Free Workplace Policy or DOT.

f. As soon as practical or next business day submit a copy of the accident/incident report (See Appendix A) to the Risk Manager.

6.1.13 Division Director or Supervisor will begin to conduct an investigation and notify Risk Management of the claim within in 24 hours using the accident/incident report form.

6.1.14 Risk Manager will review the accident/incident report form and determine if additional investigation

needs to be conducted by the Risk Manager, and/or third-party claims administrator.




6.1.15 Claim files maintained by Risk Management are confidential and exempt from public disclosure until termination

of all litigation and settlement of all claims.

6.2 General Liability Claims

6.2.1 General Liability claims include bodily injury and/or property damage, other than claims caused by licensed motor vehicles used on public roads, caused by the City's negligence or acts of omission while doing

normal duties or business.

6.2.2 Examples of general liability claims:

a. An individual alleges that they fell on a broken sidewalk.

b. A resident alleges that they were knocked down by an employee.

c. A resident alleges that their property was damaged due to City operations. This includes losses resulting from slip and fall, sidewalk accidents, pot holes, civil rights, false arrest, personal injury on City property or from operations or injury on recreation equipment, heavy equipment accidents, improper warning in construction areas, etc.

6.2.3 Employees must immediately report bodily injury or property damage claims of a third party immediately to their Division Director or Supervisor. Where possible, photos should be taken of the event and the surroundings.

6.2.4 Employee shall assist the supervisor, as necessary, in completing the accident/incident report. The purpose of the investigation is to determine the cause of the accident to prevent recurrence.

6.2.5 Supervisor’s Responsibility:

a. If at the accident site, assure proper care of injured persons.

b. Assure that proper police agency has been notified and call Risk Management to assist if necessary.

c. Complete accident/incident report. (See Appendix A) Try to maintain all evidence (Take photos of the accident scene, damage, etc.).

d. Assist Risk Management as necessary to prepare reports/investigation.

e. Arrange a drug test for the City employee, if required by City’s Drug and Alcohol Free Workplace Policy or DOT.

f. As soon as practical or next business day submit a copy of the accident/incident report (See Appendix A) to the Risk Manager.

6.2.6 Division Director or Supervisor will begin to conduct an investigation and notify Risk Management of the

claims within in 24 hours using the accident/incident report form. 6.2.7 Risk Manager will review the online accident/incident report form and determine if additional

investigation needs to be conducted by the Risk Manager, and/or third-party claims administrator.

6.2.8 The Department or Division Directors will forward any evidence and documents to the City’s Risk Manager.




6.2.9 Claim files maintained by Risk Management are confidential and exempt from public disclosure until termination

of all litigation and settlement of all claims. 6.3 Property Claims City Property claims include losses to either real or personal property owned or under the care, custody and

control of the City by a covered peril. Examples of covered perils are windstorm, fire, theft, vandalism, etc., 6.4 Workers Compensation Claims Reporting Procedure

6.4.1 Employees must immediately report all injuries to their supervisor.

6.4.2 Workers’ Compensation forms are easily obtained from the City intranet under the icon for the Department of Labor Relations and Risk Management.

6.4.3 Supervisors shall ensure that all of the documents are completed correctly, collected, and submitted as

a complete packet to the workers’ compensation specialist within 24 hours of the incident or next business day if the incident occurred during the weekend. The complete packet should include the following: First Report of Injury and the Employee Accident-Incident Report. 1. First Report of Injury or Illness (See Appendix B)

a. The supervisor and employee must complete the First Report of Injury or Illness immediately (or

as soon as possible, if an emergency situation) after an injury/illness is reported. b. If possible, provide two (2) copies to the employee (one to take to the urgent care

facility/hospital or healthcare provider and the second copy for the pharmacy, if needed).

c. This report is required by the state of Florida Department of Financial Services.

2. Accident /Incident Report (See Appendix A)

a. In addition to the First Report on Injury, the Supervisor is responsible for completing the

Accident/Incident Report. This report(s) shall be forwarded to the City’s Workers’ Compensation Specialist along with the First Report of Injury or Illness within 24 hours following the incident.

b. Employee shall assist the supervisor, as necessary, in completing the accident/incident report. c. The purpose of the investigation is to determine the cause of the accident to prevent

recurrence. 6.4.4 All employees must bring in a return to work authorization from the workers’ compensation doctor

before they may return to work, in any capacity.




6.4.5 The Supervisor must arrange a drug test for the injured employee and/or the employee causing the

accident, if required by City’s Drug and Alcohol Free Workplace Policy or DOT.

For more information on Workers’ Compensation procedures, please refer to the City Workers’ Compensation Manual.

City of Coral Gables Labor Relations and Risk Management Department

Injury Reporting Procedures

If an employee requires medical treatment:

• For Emergency Treatment: Call 911 or take the employee to the nearest hospital.

• For Non-emergency Treatment: employee must go to Physicians Health Center (PHC) (See below for nearest locations – other locations on the back of this form)

• After Hours Non-Emergency Treatment: An employee may: 1) call (305) 871-3627 (PHC’s after-hour service) and a physician will return the call within 30 minutes to discuss the injury; 2) obtain treatment the next day during PHC’s regular working hours; or 3) go to the nearest urgent care/hospital facility.

If an employee is involved in an accident/incident and does not require medical treatment, employee and supervisor must only complete step 2.

Complete the following 2 forms: (Forms can be found at Coral Gables SharePoint Intranet → Labor Relations & Risk Mgmt. →Workers Compensation Forms)

1. First Report of Injury; and 2. Employee Accident / Incident Form.

If possible, provide 2 copies of the First Report of Injury to the employee (one to take to PHC/hospital and the second copy for the pharmacy, if necessary).

Forward the completed forms to the WC Specialist, Winsome Gardner, within 24 hours of the incident or next business day if the incident occurred during the weekend.

• All employees (except sworn employees in the Police and Fire Departments) incurring on-the-job injuries must be drug/alcohol tested.

• If PHC furnishes the initial medical treatment, they will perform the drug/ alcohol screening.

• If there is an accident requiring a drug/alcohol test at night/weekend or the employee is taken to Urgent Care or Hospital, the supervisor should follow the procedures listed below:

1. Call PHC at (305)-871-3627 to connect to the PHC after-hours service and specify that an employee needs a Drug/Alcohol Collector for a drug/alcohol test.

2. Collector will return the call and provide instructions on how to proceed.

• Employee must provide a copy of the WC Medical Form DWC-25 to their supervisor after each medical visit as soon as possible. This form must be forwarded to WC Specialist via email or interoffice.

• Supervisor must review the DWC-25 form to address any work restrictions stated in the form.

•Airport 6221 NW 36th Street

Miami, FL 33166 (305) 871-3627

Mon-Fri: 7:30 AM to 6:00 PM Sat: 8:30 AM to 12:30 PM

•Kendall 7887 N. Kendall Dr., Suite #102

Miami, FL 33156 (305) 279-7722

Mon-Fri: 7:30 AM to 6:00 PM Sat: 8:30 AM to 12:30 PM

[email protected] or [email protected] Phone Number: 305-722-8692 Phone Number: 305-460-5527

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Questions: (305) 460-5527 Page 1 of 2 Labor Relations & Risk Management

CITY OF CORAL GABLES

EMPLOYEE ACCIDENT / INCIDENT REPORT

TO BE COMPLETED BY THE SUPERVISOR AND FORWARDED TO RISK MANAGEMENT IN THE OFFICE OF LABOR RELATIONS & RISK MANAGEMENT WITHIN 24 HOURS OF

THE INCIDENT ([email protected]).

Name of Injured/Claimant/Employee: __________________________________________________

Job Title: ___________________________________ Department: _____________________________________________________

Division: ___________________________________

Contact Information for Claimant (if not an employee): ___________________________________________________________________

Was Personal Protective Equipment required? Yes No Was it provided: Yes No

Was PPE being used? Yes No

If “No” explain:

Was it being used as trained by supervisor or designated trainer? Yes No


Was safety training provided to the injured employee? Yes No If “Yes”, date training was completed: ____________________


Date of Accident: __________________________ Time of Accident: __________________ Type of Incident/Accident:

Accident Location: __________________________________________ Auto W/C

Property General Liability

Treatment Rendered: ***No Medical Treatment ***First Aid Medical Treatment

If applicable, where was medical treatment sought? ____________________________________

***If employee refuses medical treatment, employee must complete and sign Addendum 1 attached to this form

Describe the accident and how it occurred:

Describe the injury and part of body affected (sprain, cut, burn, right, left, arm/foot, etc.):

Cause of accident:

mailto:[email protected]



List Witness (es): _____________________________________________________________________________

Report Date: _________________________ Prepared by: ____________________________ Title: _________________________________

Supervisor Name (Print): ____________________________________ Telephone: ____________________________

Supervisor Signature: ______________________________________ Date: ________________________________

Department Head (Print): _________________________________________ Telephone: ____________________________

Department Head Signature: ______________________________________ Date: ________________________________

Employee Signature (If Applicable) ____________________________________ Date: ________________________________

To be completed by Risk Manager:

Was hazard minimized or eliminated? Yes No N/A

If yes, what actions were taken? If not applicable, please indicate N/A

Status and follow-up action taken:

Permanent corrective action recommended to prevent recurrence:

Risk Manager Signature: _________________________________ Date: ________ ________________

Questions: (305) 460-5527 Page 3 of 3 Labor Relations & Risk Management

Rev. 02/2020



Addendum 1

TO BE COMPLETED ONLY IF EMPLOYEE REFUSES MEDICAL TREATMENT

Name of Injured: __________________________________

Job Title: __________________________________ Department: __________________________________

Division: __________________________________

I, __________________________, hereby acknowledge my refusal of medical treatment offered to me for the work related

injury I incurred on (date) _____________________ at (location) __________________ . By signing this form, I realize that I do

not necessarily affect my later eligibility for Workers’ Compensation. I acknowledge that my supervisor(s), in good faith, have

offered and made available to me an opportunity to seek necessary medical treatment. At a later time, I may request from my

employer, via my supervisor, a medical authorization to obtain medical treatment and/or observation for the above described

injury.

Employee signature: __________________________________ Date: _____________________

FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-HANDLING ENTITY

SENT TO DIVISION DATE DIVISION RECEIVED DATE

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953

PLEASE PRINT OR TYPE EMPLOYEE INFORMATION NAME (First, Middle, Last)

Social Security Number Date of Accident (Month-Day-Year) Time of Accident

AM PM

HOME ADDRESS

Street/Apt #: _________________________________________________________

City: _________________________ State: _______________ Zip: ______________

EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

TELEPHONE Area Code Number

OCCUPATION

INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED

DATE OF BIRTH

_________ / _________ / _________

SEX

M F

EMPLOYER INFORMATION

COMPANY NAME: ___________________________________________________

D. B. A.: ____________________________________________________________

FEDERAL I.D. NUMBER (FEIN)

DATE FIRST REPORTED (Month/Day/Year)

Street: _____________________________________________________________

City: _________________________ State: _______________ Zip: ______________

NATURE OF BUSINESS

POLICY/MEMBER NUMBER

TELEPHONE Area Code Number DATE EMPLOYED

_________ / _________ / _________

PAID FOR DATE OF INJURY

YES NO

EMPLOYER'S LOCATION ADDRESS (If different)

Street: _____________________________________________________________

LAST DATE EMPLOYEE WORKED

_________ / _________ / _________

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

WORKERS' COMP? YES

City: ________________________ State: _______________ Zip: ______________

LOCATION # (If applicable) ____________________________________________

RETURNED TO WORK YES NO

IF YES, GIVE DATE

_________ / _________ / _________

LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS' COMP

_________ / _________ / _________

PLACE OF ACCIDENT (Street, City, State, Zip)

Street: _____________________________________________________________

DATE OF DEATH (If applicable)

_________ / _________ / _________

RATE OF PAY

$ _________________ PER

HR WK

DAY MO

City: _________________________ State: _______________ Zip: ______________

COUNTY OF ACCIDENT ______________________________________________

AGREE WITH DESCRIPTION OF ACCIDENT?

YES NO

Number of hours per day

Number of hours per week

Number of days per week

______________________

______________________

______________________

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S.

I have reviewed, understand and acknowledge the above statement. __________________________________________________________________ _______________________________________________ EMPLOYEE SIGNATURE (If available to sign) DATE

__________________________________________________________________ _______________________________________________ EMPLOYER SIGNATURE DATE

NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL

AUTHORIZED BY EMPLOYER YES NO

CLAIMS-HANDLING ENTITY INFORMATION

1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3)

1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee’s 8TH Day of Disability _________ / _________ / _________

Entity’s Knowledge of 8TH Day of Disability _________ /_________ / _________

3. Lost Time Case - 1st day of disability _________ / _________ / _________ Full Salary in lieu of comp? YES Full Salary End Date ________/ ________ / ________

Date First Payment Mailed _________ / _________ / _________ AWW ____________________________ Comp Rate ____________________________

T.T. T.T. - 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment $___________ Interest Amount Paid in 1st Payment $__________

REMARKS:

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

INSURER CODE #

EMPLOYEE'S CLASS CODE EMPLOYER'S NAICS CODE

SERVICE CO/TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (08/2004)

Documents

Date of Issue: 02/01/2017 Accident Reporting