12.01.19 - Incident Reporting Involving the Genral Public
CITY OF BOYNTON BEACH, FLORIDA ADMINISTRATIVE POLICY MANUAL CHAPTER: 12 Risk Management Policy No. 12.01.19 SECTION: 01 Risk Management Policy Manual Page: 1 of 3 SUBJECT: 19 Incident
Reporting Involving the General Public PURPOSE To establish a procedure for reporting incidents involving the public in non-vehicular accidents. NOTE: This procedure and form are NOT
to be used for employee accident reporting. PROCEDURE 1. At the time of an accident involving a member of the public, the employee on the scene will gather information as necessary to
complete RM Form 200 (See attachment). All sections, as appropriate must be completed. 2. In cases of serious injuries, or emergency situations, the employee will call 9-1-1 for emergency
assistance and transport to the local hospital emergency room. The employee will accompany the injured person, if possible, to determine extent of injuries and gather information. If
the employee is unable to accompany the injured person, they should gather information as appropriate from family members, friends, or witnesses at the scene., 3. In cases of serious
injuries, or emergency situations, the employee must notify the Risk Management Department immediately by telephone. All information should be relayed to Risk Management as soon after
the incident as practical. The RM Form 200 should be delivered to the Risk Management Department office after all notifications have been made, both to Risk Management and within the
individual department. 4. In cases of minor injuries or no known injuries, the employee must complete the RM Form 200 and submit it to Risk Management no later than 48 hours after the
incident. 5. Additional Department specific forms should be used to provide additional information and attached to and submitted with the RM Form 200. 6. This procedure does not remove
the responsibility for the employee to notify his/her individual department supervisors concerning the incident. 1
2 DEVELOPED BY: Risk Management Department EFFECTIVE DATE: February 1, 1997 REVISED DATE: July 20, 2007 REVIEWED – no changes May 27, 2008 Kurt Bressner Kurt Bressner City Manager
CITY OF BOYNTON BEACH, FLORIDA RISK MANAGEMENT DIVISION INCIDENT REPORT FORM This form is to be used for ALL non-employee non-vehicle incidents ONLY. (Use Additional Sheets If Necessary)
Name of Injured Party: __________________________________________________________ Address: __________________________ DOB: __ __ /__ __ /__ __ Age: ______ __________________________
Tele.: Home___________ Work __________ If Minor or Incompetent Adult, was Parent/Guardian contacted? __ Yes __ No Name: __________________________ Address: __________________________
Tele: __________________________ __________________________ Date of Incident: __ __ /__ __ /__ __ Time of Incident: __ __ : __ __ __ AM __ PM Location of Incident: ___________________________________
______________________________ Description of Incident: _________________________________________________________________ _____________________________________________________________________________
_______ ____________________________________________________________________________________ Injured: __ Yes __ No Property Damage: __ Yes __ No Describe: ____________________________________________
___________________________ ____________________________________________________________________________________ First Aid Provided? __ Yes __ No By Whom: _______________________________________
Police Called? __ Yes __ No Department: _______________________________________ Ambulance called? __ Yes __ No Jurisdiction: _______________________________________ Transported? __ Yes
__ No Transported to:______________________________________ Witnesses: Name: ________________________ Address: __________________________ Tele.: ___________________ __________________________
Name: ________________________ Address: __________________________ Tele.: ___________________ __________________________ Report Completed By: ______________________ Date: __ __ /__ __
/__ __ Time: ______ Supervisor: ______________________ Department: __________________________ RM USE ONLY Site Location #: ____________ Date Date Reviewed: ____________ INCIDENT NO:
_____________ Date Received: ____________ Date Entered: ____________ Loss Prevention and Loss Control Through Proactive Strategies INCDTRPT.FRM RM 200 3