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					                                               The North-Eastern Pennsylvania Telephone Company
                                                       Motor vehicle Collision Reporting Form

                        This Form Must be Completed and Forwarded to the Safety Office within Twenty Four Hours of the Co

Date of Accident                     County                Day of the Week                     Hour (AM-PM)
Motor
Severity: Was Towing Required?       Number of Vehicles Involved      Number of Injured
Unit 1                  Unit 2                   Unit 3               Number of Killed
To Properly Locate the Accident      City-Borough-Township                        On: Street and or Highway name and or Nu
Scene be Specific and include
Information such as Cross            At Intersection:                             If not an Intersection:
 Streets and Mile Markers
Vehicle (Unit1)
Operator's Name (First, Middle, Last):                                Date of Birth
Mr.,Mrs., Ms.:
Address:                                                              Vehicle License Number and State
Street                                                                Plate:
City                                                                  Year                     Make
State                   Zip Code                                      Description of Damage to Vehicle (Unit1):
Owner's Name (First, Middle, Last):
Mr.,Mrs., Ms.:
Address:
Street
City                                                                  PA Title or Out-of-State VIN Number:
State                   Zip Code
                            Use the Following Sections to Record Information on Other Vehicles, Pedestrians or Proper
Vehicle (Unit 2)
Operator's Name (First, Middle, Last):                                Date of Birth
Mr.,Mrs., Ms.:
Address:                                                              Vehicle License Number and State
Street                                                                Plate:
City                                                                  Year                     Make
State                   Zip Code                                      Description of Damage to Vehicle (Unit 2):
Owner's Name (First, Middle, Last):
Mr.,Mrs., Ms.:
Address:
Street
City
State                   Zip Code                                      PA Title or Out-of-State VIN Number



Vehicle (Unit 3)
Operator's Name (First, Middle, Last):                               Date of Birth
Mr.,Mrs., Ms.:
Address:                                                             Vehicle License Number and State
Street                                                               Plate:
City                                                                 Year                 Make
State                   Zip Code                                     Description of Damage to Vehicle (Unit 3):
Owner's Name (First, Middle, Last):
Mr.,Mrs., Ms.:
Address:
Street
City                                                                 PA Title or Out-of-State VIN Number:
State                    Zip Code

                                                                        Injury Class            Active Restraint
                 Name                  Age      Sex         Veh #    0-No Injury             0-None
                                                                     1-Death                 1- Shoulder Harness
                                                                     2-Major Injury          only
                                                                     3-Moderate Injury       2-Seat Belt Only
                                                                     4-Minor Injury          3-Seat Belt-Harness
                                                                     9-Unknown               4-Child Restraint
                                                                                             7-Mortorcycle Helmet
                                                                       Position              8-Other
                                                                     1-Driver                9-Unknown
                                                                     2-Middle Front            Passive Restraint
                                                                     3-Right Front           0-None or Pedestrian
                                                                     4-Left Rear             1-Airbag Deployed
                                                                     5-Middle Rear           2-Airbag Not
                                                                     6-Right Rear            Deployed
                                                                     7                       3-Auto Seat Belt
                                                                     8                       8-Other
                                                                     9                       9-Unknown

Vehicle 1     Company:                                   Weather:       Rain       Snow         Clear
Insurance
Information   Policy:
Vehicle 2     Company:
Insurance                                                Police Investigation:        Yes
Information   Policy:
Vehicle 3     Company:                                   Name of Police Department:
Insurance
Information   Policy:                                    Police Report Number:

0=None                                       Vehicle Number 1:                   Vehicle Number 2:
1=1 o'clock   10=10 o'clock
2=2 o'clock   11=11 o'clock                  Initial Impact Point:               Initial Impact Point:
3=3 o'clock   12=12 o'clock
4=4 o'clock   13=Top of Vehicle              Legal Speed-MPH:                    Legal Speed-MPH:
5=5 o'clock   14=Vehicle Undercarriage
6=6 o'clock   15=Use When Initial Impact     Estimated Speed:                    Estimated Speed:
7=7 o'clock   was with a Towed Unit
8=8 o'clock   99=Unknown
9=9 o'clock
                                                                                 Collision Diagram
Instructions:
 1. Draw Diagram as Clearly
as You Can
2. Show Your Vehicle as Number 1
3. Label all streets, highways
and landmark.
4. Indicate North on the drawing
5. Complete the narrative on the
 following page and return the form
to your supervisor within 24 hours
of the collision.




Narrative: Give a detailed description of the collision immediately prior to impact, at impact and immediately after impact. Refer
Signature:


                               GENERAL INSTRUCTIONS FOR COMPLETING DRIVER'S ACCIDENT REPORT

               Use a ball point pen and print all required information. Fill in every block that is applicable. The form should be sel
               the following guidelines should be utilized and if you are unsure consult with your supervisor or the company Safe

             1. For The Accident Location---- Be sure to indicate the name of the city, Borough, or Township where the collision o
                well as the Street name or Highway Route Number. If the collision occurred at an intersection, identify the name o
                Highway Route number of the intersecting roadway.

               If the collision did not occur at an intersection, please use the nearest cross street, mile marker, or segment mark
               are signs erected along the roadside. Where possible, the signs are placed at physical features such as brides, pi
               Mile posts are generally erected along the roadsides of interstates. House numbers and utility pole numbers may
               additional points of reference. Take your time, be neat and include even minor details.

             2. For the Vehicles, Drivers and Pedestrians-----Copy information about drivers and vehicles directly from the official
                Vehicle Registration Card and Proof of Financial Responsibility Card.

             3. If there are witness to the collision it is important to secure names and contact information from them as soon as p
                Attach witness information to this form and submit it to your supervisor. Obtaining a business card is a quick and e
                to obtain contact information for follow-up later in the collision investigation.

             4. Persons Involved---- Record the names and addresses of all occupants (including the drivers) in the involved vehi
                pedestrians regardless of injury severity. Begin with the driver of vehicle 1(Unit 1), and then list the other occupant
                Repeat this procedure for any other vehicles involved .

             5. Injury, Seating, Position and Safety Restraints--- If applicable, select the appropriate codes for all occupants and p
                type of injury incurred, seating positions of all occupants and the type of restraint used.

             6. Damaged Area of the Vehicle--- Select the appropriate code for the initial impact point for each vehicle involved. T
                area, use clock points for each vehicle involved.

             7. Speed Limit and Travel Speed-----Enter the speed limit on the roadway at the collision site. If the travel speed is n
                Enter your estimated speed for each vehicle just before the collision occurred.

             8. For the Collision Diagram---The diagram is a visual representation of the collision location and the events that occ
  movement of the vehicles, identify the roadways and be sure to include the North Arrow.

9. For the Narrative--- Describe the actions of all involved persons and the vehicles before, during and after the collis
   detailed as possible, using the same vehicle/unit numbers as those shown in the collision diagram. Details are imp
   descriptions such as vehicle #1 hit vehicle # 2.
elephone Company
eporting Form

ithin Twenty Four Hours of the Collision

  Hour (AM-PM)                      Hit-Run         Y            N

              Full Name and Title of Person Completing Report

t and or Highway name and or Number

                          Feet N,S,E,W of Closest Cross Street


              Operators License Number and State

ber and State
             State:
                          Model
ge to Vehicle (Unit1):




ate VIN Number:

Vehicles, Pedestrians or Property Damage

                          Operators License Number and State

ber and State
             State:
                          Model
ge to Vehicle (Unit 2):




ate VIN Number




                          Operators License Number and State:

ber and State
             State:
                          Model
ge to Vehicle (Unit 3):
ate VIN Number:


    Active Restraint       Injury      Seating     Active     Passive
                            Type       Position   Restraint   Restraint
  1- Shoulder Harness

  2-Seat Belt Only
  3-Seat Belt-Harness
  4-Child Restraint
  7-Mortorcycle Helmet

  9-Unknown
    Passive Restraint
  0-None or Pedestrian
  1-Airbag Deployed
  2-Airbag Not

  3-Auto Seat Belt

  9-Unknown

               Foggy       Other



                  No




                         Vehicle Number 3:

                         Initial Impact Point:

                         Legal Speed-MPH:

                         Estimated Speed:
d immediately after impact. Refer to vehicles by number.
                           Date:


 'S ACCIDENT REPORT

pplicable. The form should be self explanatory. However,
r supervisor or the company Safety Officer.

or Township where the collision occurred as
n intersection, identify the name of the Street or


et, mile marker, or segment markers. Segment markers
hysical features such as brides, pipes, or intersections.
 ers and utility pole numbers may also be used as


d vehicles directly from the official Driver's License,


formation from them as soon as possible.
g a business card is a quick and easy way


ng the drivers) in the involved vehicles and all involved
 ), and then list the other occupants of vehicle 1 if any.


 iate codes for all occupants and pedestrians for the


 point for each vehicle involved. To indicate the impact


 llision site. If the travel speed is not posted , enter NP.


n location and the events that occurred. Show the
before, during and after the collision. Be as factual and
collision diagram. Details are important. Avoid
                              The North-Eastern Pennsylvania Telephone Company

                                            Accident Investigation Report

                                             Part 1 Identification Information

Employee Name:
Date Of Accident:                                  Time                       AM
Job Title:

                                             Part 2 Supplemental Information

Company: The North-Eastern Pennsylvania Telephone Company
Mailing Address: 720 Main Street
City: Forest City    State: PA   Zip Code: 18421    Telephone: (570) 785-3131

Employee Address:                                          Telephone:

City:                              State:                  Zip:
Sex:                  Age:                       DOB:                     SSN#
                                                                                          Yes
Was the employee performing regular duties at the time of the accident?

Date of Employment:                              Years of Job Experience @ This Job:
Time Shift Started:                AM            PM         Overtime?:   Yes         No

Name and Address of Physician:
Address:
City:                              State:                  Zip

If Hospitalized, Name and Address of Hospital:
Address:
City:                             State:                   Zip:

Accident Location:
Address:
City:                              State:                  Zip:

Witness Name :
Address:
City:                              State:                  Zip:

Witness Name :
Address:
City:                              State:                  Zip:

Fatality:  Yes                     No                      If Yes, Date of Death
Attach Coroner's Report:
   Yes                         No


                                    Part 3 Accident Tree (Refer to Instructions)
Nature of Injury or Illness:                               Part of the Body Affected:




Operation Location: Operation Task:             Employees Task:           Employee Body Position/Activity:




            Preceding Event:                               Type Of Accident:




Notes:
Notes:




                                        PART 4 Description And Analysis
Fully describe the accident:




What factors led to the accident?




List applicable OSHA Standards




Machinery/Equipment Involved

Manufacturer:                                                             Equip. Age:
Serial Number                                              Model:
Function:
Location:
                                                   Yes           No
Has the machine/equipment been modified?                                  If so when?
                                        Yes         No
Was the machine guarded?
If yes describe guarding and how it functioned to provide the element of safety desired:




                                                                Yes            No
Was guarding Properly:               Constructed
                                     Installed
                                     Adjusted

If no to any of the above explain:
                                                    Yes          No
Was there any mechanical failure?
Explain:




If construction related, date of contract:
The firm is:                          General contractor                   Subcontractor
Name of other contractors:
Weather conditions:

Training
Did employee receive specific training or instructions relating to safety and health on the job being performed?
    Yes                     No
Type of training:
Instructed by:
When Instructed:
Length of training
Training Records Available:             Yes                         No


                                             Part 5 Specific Actions
Specific action that will be taken:




Additional actions to consider:
Completed by:                           Date of Investigation:
Title:
Signature:


Reviewed By:                                       Date
Reviewed By:                                       Date
Reviewed By:                                       Date
Reviewed By:                                       Date
Reviewed By:                                       Date
                 Employee statement about the accident:




By:             Title:                                   Date:
Address:
City:                        State                       Zip:
Reach number:                           Cell phone:
                         Witness statement to accident




By:             Title:                                   Date:
Address:
City:                        State                       Zip:
Reach number:                           Cell phone:
                             Employer statement:
By:                                      Title:                                Date:
Address:
City:                                              State                       Zip:
Reach number:                                                 Cell phone:
                                                  Instructions:

OSHA 301 form compatibility- When this form is fully completed it is believed to satisfy the requirements of the
OSHA 301 form

Completion of this report: Parts 1 &2 may be filled out by office personnel or other staff assigned this function.
Parts 3-5 must be completely filled out by the first line supervisor, in coordination with the general manager and the
safety director.

Procedures for completing Part 3- Accident Tree

1. Fill in the top blocks of the tree:

            Describe the nature of the injury or illness: This could be a strain, laceration, contusion, abrasion,
            carpel tunnel syndrome, etc. Write in the space provided at the top of the tree

            Describe the part of the body affected (such as right index finger, right shoulder, lower back left side,
            etc.) and place this information in the adjacent space provided on the tree

            If these specific details are not fully known at this time, do not wait to begin the investigation. Fill in as
            much information as possible and continue. You can go back later and add the information as it
            becomes available.

            If investigating an accident or near miss, write none in nature and part of body and continue to the next
            section

2. Fill in the next row of the tree:

            a. Operation-Location: Where is the work being performed? Example-working at customer premise,
            25 Main St, Forest city, PA 18421

            b. Operation task: On a larger scale, what specific operation is being preformed? Example-was the
            employee placing a pole or placing cable and what specific tools were in use if the tool had any bearing
            or causative effect on the accident.
           c. Employee task: What specific task was the employee performing? Example-The employee was
           removing poles from the pole crib or lifting a box .

           d. Employee body position/activity: Briefly describe the position required by the activity that relates to
           the accident, injury or illness. For example-wrist flexed forward, hands grasping box, etc.

           e. Agency: What is the object or substance which was directly involved in the accident, injury or illness?
           For example- the machine or object struck against; the vapor or contaminant inhaled or swallowed; the
           object lifted, pulled, etc.

           f. Preceding situation or event: Determine important event(s) that lead to the accident, injury or illness.
           These may be considered triggering events, situations or circumstances necessary for the accident to
           occur.

           g. Type of accident: What general type of accident occurred? Example- fall off of a platform, slip on oil,
           struck by machine tool, contact with electricity, exposure to hazardous substances.

3. Trace each factor in more detail: Work from each of the key factors identified above. Ask why each of the
factors is necessary, or why they occurred. Under each factor write the key words describing "why" and draw a line
to connect the 2. It is possible for there to be more than one reason "why under each factor, so be sure to include
all the you discover

4. Repeat the process-build the tree: The process in step 3 can be repeated until all questions are answered for
each path of the tree. Dead ends are either unanswered questions that require additional investigation or pathways
that have been resolved as far as practical.




      How Much Does an Injury or Incident CostThe North-
         Eastern Pennsylvania Telephone Company?
Fully loaded salary of the injured employee for any hours paid
after the incident (Wage continuation)

Workers’ Compensation benefits paid to the employee

Medical fees associated with the injury

Fully loaded salary of the supervisor for hours spent responding to the

Fully loaded salary of the management team for hours spent responding to
the incident, supporting incident analysis, reviewing corrective actions, and
dealing with regulatory agency and customer issues arising from the incident



Fully loaded salary for administrative support needed to ensure the proper
completion of all forms, to work with the Workers’ Compensation Insurance
to manage the claim and to pay invoices for costs under the deductible
Fully loaded salary for administrative support needed to ensure the proper
completion of all forms, to work with the Workers’ Compensation Insurance
to manage the claim and to pay invoices for costs under the deductible



Repair of damaged equipment or property

Implementation of engineering, administrative or personal protection controls


Loss in productivity due to incident

Loss in sales or customers due to incidents

Overtime to cover missed shifts


                                                     Total
Note: Use Back Space To Clear Cells
Company




          PM




          No
Body Position/Activity:
the job being performed?
fy the requirements of the


aff assigned this function.
  the general manager and the




on, contusion, abrasion,
tree

oulder, lower back left side,


n the investigation. Fill in as
d the information as it


body and continue to the next




rking at customer premise,


ormed? Example-was the
use if the tool had any bearing
mple-The employee was


 y the activity that relates to
asping box, etc.

 the accident, injury or illness?
 ant inhaled or swallowed; the


 he accident, injury or illness.
necessary for the accident to


all off of a platform, slip on oil,
bstances.

e. Ask why each of the
scribing "why" and draw a line
 factor, so be sure to include


questions are answered for
onal investigation or pathways




tThe North-
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                                The North-Eastern Pennsylvania Telephone Company

                                               Hazardous Condition Report


                                                      Part 1
To:                                            Department:
                                                                                                  Yes
From:                              Phone #:                            Supervisor notified:

All affected employees notified:       Yes                       No
                                             Supervisor Acknowledgement
I certify that I have reviewed the information contained in this hazard report and will take the necessary steps to
ensure correction
Name:                                                        Signature:
Title:
Date:
Time:
                                                  Hazard Description
Hazard Description-Be specific as to location:




                                      Corrective Action Recommendations




                             Investigation Of The Hazard-Immediate Action Taken
                                                Follow-up Action
Person Contacted:                              Date:                                              AM
                                                                    Time:
Remarks                                        Estimated Completion Date




                                          Summary Of The Investigation




                                                  Acknowledgement
I certify that I have investigated the hazards reported in this hazard report and will take necessary steps to ensure
corrections of the safety deficiencies noted:
Name
Title:                                           Signature:
Date:                                    AM         PM
Time:
                                         Report Form Retention Information
Report #                              Date Received:
Estimated Completion Date:
Forwarded To:                                    Date:
Person Responsible:
Attachments                   Yes                    No

The contents of this document are not for disclosure outside of The North-Eastern Pennsylvania Telephone
Company and may only be modified with the approval and supervision of the Safety Officer.
                No




e necessary steps to
                PM




essary steps to ensure




 vania Telephone
r.
Incident-Near Miss                The North-Eastern Pennsylvania Telephone Company

                                          Incident/Near Miss Investigation Report

                                                 Part 1 Identification Information

    Type of incident
    Date of incident                                 Time                      AM
    Location of incident

                                                 Part 2 Supplemental Information

    Company: The North-Eastern Pennsylvania Telephone Company
    Mailing Address: 720 Main Street
    City: Forest City    State: PA        Zip Code: 18421  Telephone: (570) 785-3131
                                       Part 3 Non-Employees Injury Information
    Was anyone injured as a result of this incident?            Yes                    No
    Name:                                                  Telephone:
    Address:
    City:                               State:       PA    Zip:
    Sex:                 Age:                        DOB:                SSN#
                                                                                       Yes
    Was the injured person employed by a contractor doing work for NEP?
    Was the injured person directly responsible for the incident?
    Was the injured person a bystander?
    Was the injured the driver of passanger of a motor vehicle?

    If employed by a contractor to NEP how long was the individual employed?
    Time Shift Started:                   AM          PM      Overtime?:       Yes     No

    Name and Address of Physician:
    Address:
    City:                              State:                Zip

    If Hospitalized, Name and Address of Hospital:
    Address:
    City:                             State:                 Zip:

    Incident location:
    Address:
    City:                              State:                Zip:

    Witness Name :
    Address:
    City:                              State:                Zip:

    Witness Name :
    Address:
City:                                State:                Zip:

Fatality:  Yes                       No                    If Yes, Date of Death
Attach Coroner's Report:
    Yes                     No


                                          PART 4 Description And Analysis
Fully describe the accident/near miss::




What factors led to the accident?




List applicable OSHA Standards




Machinery/Equipment Involved

Manufacturer:                                                             Equip. Age:
Serial Number                                              Model:
Function:
Location:
                                                    Yes          No
Has the machine/equipment been modified?                                  If so when?
                                        Yes         No
Was the machine guarded?
If yes describe guarding and how it functioned to provide the element of safety desired:




                                                                  Yes          No
Was guarding Properly:               Constructed
                                     Installed
                                     Adjusted

If no to any of the above explain:
                                                     Yes            No
Was there any mechanical failure?
Explain:




If construction related, date of contract:
The firm is:             General contractor                         Subcontractor
Name of other contractors:
Address:
City:                                 State:                 Zip:
Weather conditions:
Training
Did the injured contractor's employee receive specific training or instructions relating to safety and health frelating
to the task being performed?
    Yes                       No
Type of training:
Instructed by:
When Instructed:
Length of training
Training Records Available:                Yes                     No




If construction related, date of contract:
The firm is:             General contractor                         Subcontractor
Name of other contractors:
Address:
City:                                 State:                 Zip:
Telephone number:
Weather conditions:
Training
Did the injured contractor's employee receive specific training or instructions relating to safety and health frelating
to the task being performed?
    Yes                       No
Type of training:
Instructed by:
When Instructed:
Length of training
Training Records Available:                Yes                     No


                                               Part 5 Specific Actions
Specific action that will be taken:
Additional actions to consider:




Completed by:                                             Date of Investigation:
Title:
Signature:


Reviewed By:                                                               Date
Reviewed By:                                                               Date
Reviewed By:                                                               Date
Reviewed By:                                                               Date
Reviewed By:                                                               Date
                                           Statement about the accident:




By:                               Title:                                   Date:
Address:
City:                                        State                       Zip:
Reach number:                                           Cell phone:
                                         Witness statement to accident




By:                             Title:                                   Date:
Address:
City:                                        State                       Zip:
Reach number:                                           Cell phone:
                                             Employer statement:




By:                             Title:                                   Date:
Address:
City:                                        State                       Zip:
Reach number:                                           Cell phone:



     How Much Does an Injury or Incident CostThe North-
        Eastern Pennsylvania Telephone Company?
Fully loaded salary of the injured employee for any hours paid
after the incident (Wage continuation)
Workers’ Compensation benefits paid to the employee

Medical fees associated with the injury

Fully loaded salary of the supervisor for hours spent responding to the

Fully loaded salary of the management team for hours spent responding to
the incident, supporting incident analysis, reviewing corrective actions, and
dealing with regulatory agency and customer issues arising from the incident



Fully loaded salary for administrative support needed to ensure the proper
completion of all forms, to work with the Workers’ Compensation Insurance
to manage the claim and to pay invoices for costs under the deductible



Repair of damaged equipment or property

Implementation of engineering, administrative or personal protection controls


Loss in productivity due to incident

Loss in sales or customers due to incidents

Overtime to cover missed shifts


                                                      Total
Note: Use Back Space To Clear Cells
Company

ort




          PM

               ear




          No
to safety and health frelating




to safety and health frelating
tThe North-
mpany?
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DOCUMENT INFO
Description: Company Vehicle Employee Contract document sample