Post-accident documentation summary

DOCUMENTATION SUMMARY

To Be Completed by the Supervisor assigned to investigate the accident/incident.

Return to (insert appropriate company official here) within 24 Hours of the accident/incident.

1) Accident Report #: __________________________________________________________________

2) Incident Report #: __________________________________________________________________

3) Location of Accident/Incident:

___________________________________________________________________________________________

4) Description/Details: ___________________________________________________________________________________________

___________________________________________________________________________________________

5) Date of Accident/Incident: __________________ Time: ___________________

6) Accident/Incident Report Date: __________________ Time: ___________________

7) Name of Employee: _________________________________________________________________

8) Identification Number: _______________________________________________________________

9) Employee’s Position: _________________________________________________________________

10) Result of Accident/Incident:

§ 655.4 Definitions. Accident means an occurrence associated with the operation of a vehicle, if as a result: (1) An individual dies; or (2) An individual suffers bodily injury and immediately receives medical treatment away from the scene of the accident; or (3) With respect to an occurrence in which the mass transit vehicle involved is a bus, electric bus, van, or automobile, one or more vehicles (including non-FTA funded vehicles) incurs disabling damage as the result of the occurrence and such vehicle or vehicles are transported away from the scene by a tow truck or other vehicle.

a) Was there a fatality? ____**Yes ____No

**If the accident resulted in a fatality of any person involved in the accident/incident (employee, passenger, or general public) the transit driver, and any other employee who may have been a contributing factor to the accident, will be required to undergo both a post-accident alcohol test and post-accident drug test. Alcohol test should be performed before Drug Specimen test.

b) Was anyone transported from the scene of the accident for medical attention? ____Yes ____No

If yes, any transit employee who cannot be discounted as a contributing factor to the accident is required to undergo both a post-accident drug and post-accident alcohol test.

c) Was there disabling damage* to any vehicle involved? ____Yes ____No

If YES, any employee who cannot be discounted as a contributing factor to the accident is required to undergo both a post-accident alcohol and post-accident drug test.

§ 655.4 Definitions. Disabling Damage means damage that precludes departure of a motor vehicle from the scene of the accident in its usual manner in daylight after simple repairs; or damage to a motor vehicle, where the vehicle could have been driven, but would have been further damaged if so driven. Exclusions: (i) Damage that can be remedied temporarily at the scene of the accident without special tools or parts. (ii) Tire disablement without other damage even if no spare tire is available. (iii) Headlamp or tail light damage. (iv) Damage to turn signals, horn, or windshield wipers, which make the vehicle inoperable.
d) Can the driver be completely discounted as a contributing factor to the accident? ____Yes ____No

Note: If you discount the driver as a contributing factor, it should be well documented (see question 11).

e) If the supervisor determined that drug and alcohol testing is required, can the performance of any other safety sensitive employee (e.g., maintenance/mechanics, dispatcher, etc.), whose performance may have contributed to the accident (as determined by the supervisor using information available at the time of the accident), be completely discounted as contributing to the accident? ____Yes ____No

11) Was an employee sent for post-accident drug and alcohol testing? ____Yes ____No

a) If YES, was testing performed under DOT Authority using DOT forms? ____Yes ____ No (or)

b) If YES, was testing performed under independent Company Authority? ____Yes ___No

(Must use non-DOT testing forms. Must be authorized in D&A Testing Policy)

c) If NO: ______Accident/Incident did NOT meet FTA’s definition of an Accident to require DOT testing.

d) If NO: ______Other Reason (explain): _________________________________________________

________________________________________________________________________________
12) Supervisor Making Determination: __________________________________________________________

13) Employee Notification of D&A Testing: Date: _______________Time:______________

14) Alcohol Test Conducted: Date: ______________Time:______________

15) Drug Test Conducted: Date: ________________Time ______________

16) Did the employee(s) refuse the test? ____Yes ____No

If Yes, explain:______________________________________________________________________

17) Did the employee leave the scene of the accident without just cause? ____ Yes ____ No

If yes, explain: ______________________________________________________________________

18) Did either the drug or alcohol test occur more than two hours from the time of the accident? ____ Yes ___No

If yes, explain: ______________________________________________________________________

19) If an alcohol test was not conducted because more than 8 hours had elapsed before the employee was available for the alcohol test, please explain:

_________________________________________________________________________________________

20) If a drug test was not performed because more than 32 hours had elapsed before the employee was available for a drug test, please explain:

_________________________________________________________________________________________

21) Is the employee involved currently taking any Prescribed or Over-the-Counter medicines? ____ Yes ____No

__________________________________________________________________________________________

To Be Completed By DAPM/DER Test Result: ____ Positive ____ Negative ____Test Cancelled

Attachments: _____Order to Test _____Breath Alcohol Testing Form (ATF)