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Supervisor's Damage/Accident Report

  1. 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
  2. City Fleet Vehicle/Equipment Damaged?*
    If Yes, Fleet Service Request Required. (Clicking Yes will display link)
  3. Employee Injury?*
    The employee MUST fill out a Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form (Clicking Yes will display link)
  4. Private Property Damage?*
    Any and all property damage must be listed to include an Employee's private property if any.
  5. Enter City Vehicle Number
  6. Year Make Model Color
  7. State / Number
  8. Name / Phone Number
  9. State Issued DL Number
  10. DESCRIPTION OF ACCIDENT / DAMAGE
  11. Did Napa PD Investigate?*
  12. Citizen Injury?*
  13. Were City Paramedics Called?*
  14. Be specific/include the name of the person administering
  15. From Fleet Service Request submission
  16. Must be filled out by the Supervisor
  17. 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.
  18. Leave This Blank:

  19. This field is not part of the form submission.