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Orange County Accident Report <br />Control # (assigned by others) <br />Name of employee reporting accident/incident <br />~te ~ time of accident: <br />Exact location of accident: <br />Drua Test Required: Yes No <br />Date received in Purchasing: <br />Dr ~ Testi done as r wired? Yes No (If no, De artment Head to rovide written ex lunation) <br />Instructions: <br />• Complete all parts of the accident report. <br />• Attach-the exchange slip from the other party to the accident report. <br />Ensure that your department head or supervisor signs accident report. <br />• Ensure report is forwarded to Purchasing Direc#or (extension 2652, fax 644-3001, E-mail- pjones) by the <br />first business day after accident. Hand delivery or courier is fine as long as the report arrives within the <br />specified period. E-mail and fax are also acceptable means of delivery. <br />REMEMBER! CERTAIN ACCIDENTS REQUIRE DRUG TESTING WITHIN A SPECIFIED PERIOD AFTER <br />THE ACCIDENT. (Personnel Ordinance 11.2.4) <br />Type of accident: (Check all that apply) <br />Vehicles <br />Damage to County owned vehicle (Report in Sections A & C) <br />Damage to County employee's personal vehicle being used for County business (A & C) <br />Damage to vehicle of another party (Report in Sections B & C) . <br />- er <br />Non Vehicle Prop ty <br />Damage to County property (e.g. Vandalism of building) (report in sections B ~ C) <br />Damage to Non-County property (e.g. Employee hits a mailbox) (report in sections B & C) <br />Injury to anon-employee on County property. (e.g. Someone falls in County bldg.) (provide ** info <br />requested in Section B and provide detailed description in section C) <br />Z'niuries) to County employees must be reported on worker's comp forms through the Personae/ Deportme <br />A. Employee Information: (Provide the following information for County employee involved. <br />Complete only those questions that may be applicable #o the situation you are reporting.) <br />Name of County employee: <br />Department: Division:. <br />Your County phone number: <br />Date of Birth: <br />Driver License Number: <br />County vehicle # V.I.N. Plate #: <br />Year/MakelModel of County vehicle: <br />If damaged property is not n vehicle, describe property damaged: (use extra sheets if needed) <br /> <br />