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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

   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