RCUH Policies and Procedures
STATE OF HAWAII INTERNAL DEPARTMENT USE
INCIDENT / ACCIDENT REPORT (INFORMATION ON INJURY/SAFETY/HEALTH MATTERS)
SELECT CATEGORY FOR THIS REPORT:
RECORDS ONLY INCIDENT: AN EVENT WHICH MAY OR COULD HAVE RESULTED IN PHYSICAL HARM OR PROPERTY DAMAGE BUT NO CLAIM IS EXPECTED TO BE MADE.
ACCIDENT: AN EVENT WHICH RESULTED IN PHYSICAL HARM OR PROPERTY DAMAGE.
RULES FOR HANDLING NEW REPORTS
1. NEVER ADMIT LIABILITY. AVOID SAYING THAT THE EVENT OR SITUATION WAS UNSAFE, DANGEROUS, HAZARDOUS, UNPROFESSIONAL, SUBSTANDARD OR OTHERWISE DEFICIENT.
2. REFER TO THE INCIDENT OR ACCIDENT AS AN UNFORTUNATE EVENT OR SITUATION.
3. ASK QUESTIONS TO GATHER PERTINENT FACTS AND TO CLARIFY IMPORTANT POINTS.
4. REVIEW YOUR UNDERSTANDING OF THE INCIDENT OR ACCIDENT WITH THE CALLER.
5. INFORM THE CALLER THAT THE MATTER WILL BE INVESTIGATED PROMPTLY AND THAT FOLLOW-UP WILL BE MADE.
6. EXPRESS SINCERE THANKS FOR THE CALLER’S INFORMATION AND/OR SUGGESTION TO CORRECT, PREVENT PROBLEMS OR TO PROMOTE PUBLIC HEALTH AND SAFETY.
7. NEVERCOMMITTOPAYANYMEDICALBILLS.
8. REMEMBER – YOU ARE THE FIRST IMPORTANT STEP IN LOSS CONTROL FOR THE STATE OF HAWAII. IF THE CALLER IS LEFT FEELING THAT THE STATE IS UNCONCERNED, A LAWSUIT COULD BE INITIATED.
Completion of this report includes prompt presentation of the report to your immediate supervisor for investigation, then to the departmental risk management coordinator for review. Prompt reporting of the incident/accident will allow the State to investigate and collect facts while they are still available and fresh in mind. Accuracy is always in the best interests of the State.
Form RML-001 (08/16) Part 1 of 3
Form RML-001 (08/14) Part 1 of 3
PRINT LEGIBLY OR TYPE
STATE OF HAWAII
INCIDENT / ACCIDENT REPORT (INTERNAL DEPT USE)
1. DATE STATE RECEIVED NOTICE OF LOSS: _________________
2. STATE EMPLOYEE WHO RECEVED NOTICE OF LOSS: Name: _____________________________________
Direct Phone: ______________________ Email: ____________________________________________ 3. NAME OF CALLER: _______________________________________________________________________ 4. CALLER’S ADDRESS: ______________________________________________________________________ 5. CALLER’S PHONE #: ___________________ 5A. CALLER’S EMAIL: ________________________________
INCIDENT INFORMATION AS REPORTED BY CALLER:
ACCIDENT
Date: _______________ Time: ___________ Location: _____________________________________ Type of Incident: Bodily Injury Property Damage Other: ___________________________ Description:
INJURED PERSON
Name: _________________________________ Age: _______ Telephone: ______________________ Address: ____________________________________________________________________________ Nature & Extent of Injury: (list additional injured persons on back of form)
PROPERTY DAMAGE
Owner Name: _______________________________________ Telephone: ______________________ Description of Property: _______________________________________________________________ Describe Damage: ____________________________________________________________________ Where can property be inspected: _______________________________________________________
WITNESSES
Name Address Telephone _________________________ _____________________________________ ____________________ _________________________ _____________________________________ ____________________ _________________________ _____________________________________ ____________________
POLICE REPORT
Was a Police Report completed? Yes No Uncertain Police Report Number: __________________________________
ADDITIONAL INFO
Any additional information to provide?
Form RML-001 (08/16) Part 2 of 3
Form RML-001 (08/14) Part 2 of 3
STATE OF HAWAII
FOLLOW-UP TO REPORT OF INCIDENT / ACCIDENT
CLAIMANT (OR CALLER): _________________________________ OCCURRENCE DATE: _______________
OUTLINE WHAT INVESTIGATION WAS COMPLETED UPON NOTICE OF INCIDENT / ACCIDENT:
NAME OF STATE EMPLOYEE WITH MOST KNOWLEDGE OF INCIDENT:
FIRST: ________________________ LAST: ____________________________
EMAIL: _________________________________________ WORK PHONE #: __________________________ DEPT: ______________________ DIVISION: ___________________ BRANCH: _________________________
EXPLAIN NATURE OF INJURY OR DAMAGE TO PROPERTY:
OBJECT/EQUIPMENT/SUBSTANCE INFLICTING: PERSON WITH MOST CONTROL OF INFLICTING ITEM:
CLEARLY DESCRIBE HOW THE INCIDENT/ACCIDENT OCCURRED:
PHOTOGRAPHS: Yes No WITNESS NAMES? Yes No (If yes to either, attach to report)
WHAT ACTION HAS OR WILL BE TAKEN TO PREVENT RECURRENCE? LIST IN SEQUENCE:
1. ________________________________________________________________________________ 2. ________________________________________________________________________________
INVESTIGATED BY: _________________________ _________________________ _________________ (Supervisor – Print Name) Signature Date Signed
DEPARTMENT/UNIT: ____________________________________
Supervisor Phone: ________________ Supervisor Email: ___________________________
REVIEWED BY: _____________________________ PHONE: ___________________ DATE: ____________ (Risk Management Coordinator)
EMAIL: ________________________________________________
Form RML-001 (08/16) Part 3 of 3
LOSS SEVERITY POTENTIAL: PROBABLE RECURRENCE RATE:
MAJOR SERIOUS MINOR FREQUENT OCCASIONAL RARE YES NO UNCERTAIN
IS A CLAIM BEING MADE?
Form RML-001 (08/14) Part 3 of 3