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Supervisor's Damage/Accident Report

2. Supervisor's Damage/Accident Report
   This Form is for Documenting Damage and/or Accidents. The form will be sent to Department Head, Risk Management & Fleet Division
4. How to Report a Work-Related Injury, Illness or Exposure
   How to Report a Work-Related Injury, Illness or Exposure
5. Supervisor Accident Reporting Protocol
   Supervisor Accident Reporting Protocol
6. Staff Accident Reporting Protocol
   Staff Reporting Protocol
7. Fleet Accident Reporting Vehicle Card
   Fleet Accident Reporting Vehicle Card
11. City Fleet Vehicle/Equipment Damaged?*

    1. Yes

    1. No

    If Yes, Fleet Service Request Required. (Clicking Yes will display link)
12. Click for Fleet Service Request
    Fleet Service Request Link

    Complete Service Request before proceeding further. Number required below on this form.
14. Employee Injury?*

    1. Yes

    1. No

    The employee MUST fill out a Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form (Clicking Yes will display link)
15. Click for Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure
    Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form
17. Private Property Damage?*

    1. Yes

    1. No

    Any and all property damage must be listed to include an Employee's private property if any.
19. First Name*
20. Last Name*
21. Employee ID*
23. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
24. Department*
    -- Select One --Community DevelopmentFinanceFire DepartmentHuman ResourcesParks and RecreationPolice DepartmentPublic WorksUtilities
25. Employee Email Address*
27. Location of Incident*
29. Employee(s) Involved*
30. Vehicle Number*
    Enter City Vehicle Number
32. Private Vehicle(s)
    Year Make Model Color
33. Private Vehicle License Number
    State / Number
34. Private Insurance Info
    Name / Phone Number
35. Private Vehicle DL Number
    State Issued DL Number
37. Name(s), Address(es), and Phone Number(s) of Witnesses
39. Upload Photo of Damage #1 (Required)*
40. Upload Photo of Damage #2 (Optional)
42. Upload Photo of Damage #3 (Optional)
43. Upload Photo of Damage #4 (Optional)
45. Upload Photo of Damage #5 (Optional)
46. Upload Photo of Damage #6 (Optional)
50. DESCRIPTION OF ACCIDENT / DAMAGE
52. Did Napa PD Investigate?*

    1. Yes

    1. No
53. PD Incident Number
55. Description of event. Include any Contributing Factors to Accident or Damage
57. Citizen Injury?*

    1. Yes
    2. No
58. Were City Paramedics Called?*

    1. Yes
    2. No
59. FD Incident Report Number
61. If Citizen Injury: Was First Aid Administered?
    Be specific/include the name of the person administering
62. Citizen(s) Involved
63. Citizen(s) Involved Address / Phone
65. List all damages to Vehicle/Equipment/City Property
66. Fleet Service Request Number*
    From Fleet Service Request submission
70. What Department actions were taken to prevent future damage/accident?*
    Must be filled out by the Supervisor
74. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
76. Electronic Signature (Supervisor submitting form)*
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field