Get documents about "Incident Report Forms
W
Description
Incident Report Forms document sample
Document Sample
INCIDENT REPORTING
for the
RISK MANAGEMENT FUND
September 2006
Why Report Incidents
The State can be sued for
claims of negligence
(torts/liability) against
its agencies, employees,
or volunteers.
2
Tort Liability Risk
Management Program
Program was established by the 1995 ND
Legislature following a 1994 Supreme Court
decision that eliminated the State’s sovereign
immunity
The Court’s position was that the State should
be held responsible for the negligence (torts) of
its agencies, employees, or volunteers
3
Tort Liability Risk
Management Program
When the Legislature established the Fund, it
created N.D.C.C. Ch. 32-12.2, known as the “Tort
Claims Act”
• Act governs claims against the State and State employees
acting within the scope of employees’ employment
• The Legislature also established:
Risk Management Division as a part of the Office of
Management and Budget
Risk Management Fund
4
What Should Be Reported?
ALL incidents and accidents involving
non-employees AND employees, no matter
how insignificant they seem.
This documents relative facts.
Provides a loss control tool.
5
Will The Entity's Contribution To The Risk
Management Fund Increase With The
Number Of Incident Reports Filed?
NO . . .
Incident reports are not a factor in determining an
entity’s contribution amount. Incident reports are
entered into a database to track trends and
implement loss control procedures. Only when an
incident turns into a claim by the injured person
filing a Notice of Claim form with the Risk
Management Division, does it factor into an entity’s
contribution amount.
6
Forms To Use When Reporting
Incidents And Accidents
SFN 50508 for general incidents/accidents (i.e. slip and falls,
injuries, property damage).
SFN 51301 for accidents involving state owned or leased vehicles.
SFN 53601 for incidents involving medical treatment rendered or
advice received from State employees to a third party at a State
owned or managed medical facility (i.e. State Hospital, Family
Practice Centers).
Complete and submit the report forms on-line at
www.nd.gov/risk/riskvision/application/sond/.
The most current version of the paper forms are at
www.nd.gov/risk/forms/.
7
Why Is It Important To Use Risk
Management’s Forms?
Incident/Accident reports, investigation
reports, or other Risk Management Fund
records of a pending or reasonably predictable
claim against the State or a state employee are
privileged and exempt from the open records
law, pursuant to N.D.C.C. § 32-12.2-11.
This means that only Risk Management has
the authority to decide if these forms may be
disclosed under an open records request while
a matter is pending.
8
Why Is It Important To Use Risk
Management’s Forms?
To Secure The Statutory Protections:
If an entity uses a report form other than SFN 58508, 51301
or 53601, it is important that any documents prepared
regarding an incident/accident are attached to the
Risk Management forms; and
If any documents prepared regarding an incident/accident
are filed after the original report form is filed, it is important
to identify that it is to be attached to the particular Risk
Management form.
9
The Timing Of Reporting Incidents
Prompt Reporting is Critical!
Protects the State’s interests.
Preserves the evidence and information
while the facts are fresh.
Helps contain costs.
Enables corrective action to be taken to avoid
reoccurrence.
Late or inaccurate reporting could jeopardize the
defense of a claim or lawsuit!
10
Why Is My Role In Preserving
Evidence So Important?
A potential claimant has 180 days (approximately 6
months) to file a Notice of Claim form with the Director
of OMB. It is best to document all of the information
you have while it is fresh in your mind. You may not be
asked again about the incident until 6 months after it
occurred and the details, if not the entire incident, may
be forgotten.
The prompt reporting and preservation of evidence
will also aid in the preparation and defense of a claim,
as well as early resolution of a claim.
11
The When And Who Of Incident
Reporting - General
Incidents involving serious injury (death, potential for death,
or potential for serious or permanent injury) or extensive
property damage, immediately:
• Call 9-1-1, and
• Report to the Risk Management Division
(701-328-7584).
All other incidents should be reported on-line to the Risk
Management Division within 24 hours of the occurrence or
notification.
12
The When And Who Of Incident
Reporting - Vehicle
State Fleet vehicle accidents involving serious injury (death,
potential for death, or potential for serious or permanent
injury) or extensive property damage, immediately:
• Call 9-1-1,
• Call State Radio (1-800-472-2121) and report that
“this is a Risk Management accident”.
All other incidents should be reported on-line to the Risk
Management Division and State Fleet within 24 hours of the
occurrence or notification.
13
Who Should Fill Out A Report Of An
Incident/Accident?
The involved state employee and supervisor, or the person
with whom the injured person makes contact by phone or in
person should work with the entity’s Risk Management
Contact to complete the form. As either the person
involved, a witness, or the first one on the scene, he/she will
have the crucial information to complete the initial Report.
Contact the Agency Risk Management Contact about
procedures for submitting the report on-line.
14
What To Do When Notified, Witness, Or Are
Involved In An Incident Or Accident
1. Secure the situation. Do not endanger yourself
or others.
2. Determine and document:
Names and roles of the people present;
Equipment, vehicles, or other property involved, along
with their placement and condition;
Weather conditions and visibility;
State of the general environment, including road
surface, placement of signs, etc.
15
What To Do When Notified, Witness, Or Are
Involved In An Incident Or Accident
3. Notify your Risk Management Contact. The
Contact will know the proper reporting
procedures and the steps to implement
necessary corrective actions. If the situation
warrants, you may need to take corrective
actions immediately.
16
What To Do And Say At The Scene Of An Accident
Or When Contacted For Information About The
Incident/Accident
Do not admit fault, liability, or negligence.
Exchange general contact/identification & liability
coverage information with the other party & law
enforcement. When discussing the matter, give only facts,
not opinions.
Statements & details can be provided to the entity’s Risk
Management Contact, Risk Management, attorney’s for the
State, & adjusters for the State. Contact Risk Management
before making statements or discussing the matter with
anyone else, i.e. media, general public, insurance adjuster for
other party, attorney for other party.
17
What To Do And Say At The Scene Of An Accident
Or When Contacted For Information About The
Incident/Accident
Do not put anything in writing other than what is required for
the incident report, investigation materials, and other items
approved by Risk Management!
If asked to be interviewed by a representative of the other
party’s insurer or an attorney, advise them the questions must
be submitted to Risk Management in writing. You should not
release information about the incident/accident unless
authorized by Risk Management.
18
Explaining The State’s
Liability Coverage
You can tell other parties and/or law enforcement that
liability coverage is the “North Dakota Risk Management
Fund, pursuant to N.D.C.C. ch. 32-12.2.”
There technically is not a policy number because the
coverage is by statute, rather than an independent insurance
company. State fleet vehicles should have an insurance card
with this information in the packet given to the driver at
checkout. See an example of the card on the next 2 slides.
19
Explaining The State’s
Liability Coverage
North Dakota Risk Management Fund
Vehicle Liability Coverage
pursuant to
N.D.C.C. ch. 32-12.2
Effective 07/01/97
Report all accidents with serious injury (death, potential for
death, or potential for serious or permanent injury) or
extensive property damage immediately to:
• 9-1-1, and
• State Radio (1-800-472-2121) and report that
“this is a Risk Management accident”.
State Employee accident reporting instructions on reverse side
20
Explaining The State’s
Liability Coverage
State Employee Accident Reporting Instructions
1. Obtain names and address of:
a. drivers and occupants of other cars, and
b. injured
2. Obtain insurance information of other drivers involved.
3. Obtain names and address of all witnesses. Witnesses
may help to prove you were blameless in the accident.
4. Make no comment or statement regarding the accident
except to police or a representative of the State.
5. Within 24 hours, report the accident on-line to Risk
Management and State Fleet at www.nd.gov/risk/.
6. Contact for Questions: Risk Management 701-328-7584
and State Fleet 701-328-1472.
21
How Can I Fill Out A Report If I Did
Not See It Happen?
If you were the first person the potential claimant was in
contact with after the incident occurred, even if you did not
see it happen, you are the person with the most first-hand
information and are in the best position to complete the form.
Plus, you have the opportunity to obtain more information.
For example: if possible, go to the location of the
incident to view the site; take pictures; note the
weather; note the conditions of the area; identify
witnesses, if any; implement corrective actions, if
necessary.
You Are A Key To Preserving The Evidence!
22
How Can I Fill Out A Report If I Did
Not See It Happen?
State only the facts, not opinions. You should not state
what you “think” happened. Only document what the
injured person told you and what you are able to verify
(such as weather conditions or condition of the location).
Example:
“I did not see the incident. At 9:00 a.m., Jane Doe reported to me
that she was walking to the east building entrance for an
8:30 am meeting and she slipped on a patch of ice on the sidewalk.
I accompanied Jane to the area she identified as the
location of the incident. I noted that the sidewalk was clear and dry (OR
I noted a patch of ice that had not been salted). Pictures taken.”
23
How To Fill Out A Report If The Event Isn’t
Reported Until Days, Weeks,
Or Even Months After It Happened
Do the best that you can. Document what the
potential claimant reported to you and note that you
were not aware of the event until you received the
recent report.
If the entity has records/documents/logs to verify or
dispute the claim (i.e. we did not have equipment and
crew at the location and time reported), please note and
attach documentation.
24
What If The Injured Person Wants To Fill
Out The Incident Report Form?
The potential claimant should not be given the
incident/accident forms to complete. The initial incident and
accident reports contain the State’s full version and facts of
how the incident happened.
The potential claimant should be informed that a report will
be filed with the Risk Management Division and a Notice of
Claim form will then be mailed directly to them (OR if
requested, a copy of the form can be given to them from the
website www.nd.gov/risk/forms/docs/sfn50552.pdf). The
Notice of Claim form will give them an opportunity to tell
their version and facts of the events.
25
What If The Potential Claimant Wants The Entity To
Repair Its Damage Immediately And/Or Ask For A
Commitment For Payment?
Explain to the potential claimant that you and your
entity do not have the authority to make that
determination.
Tell him/her that a report of the incident/accident
will be forwarded to the Risk Management Division
for processing. In addition, the Risk Management
Division will contact him/her.
Refer the potential claimant to the Risk Management
Division for questions (701-328-7584).
26
Completing SFN 50508
Department Location Code
Fill in your Department Location Code.
If you are not sure of your entity’s Code,
a complete list of the Codes can be
found in Section 3 of the Risk
Management Manual.
27
Completing SFN 50508
Differences Between The Incident Box
And The Claim Form Requested Box
When you only check the Incident box, you are telling Risk
Management that the purpose of the report is to give
notification of an incident, but Risk Management does not
need to get in touch with the person involved or send
him/her a Notice of Claim form.
When you check the Claim Form Requested box, you are
telling Risk Management that a Notice of Claim form needs
to be sent to the person involved because he/she indicated
that they will be seeking compensation for the loss.
28
Completing SFN 50508
Destruction Hold Notice
This gives immediate notification to Risk Management
and the State entity that any documents regarding the
incident must be retained until Risk Management and
legal counsel can determine the scope of the matter. This
prevents any documents, records, or evidence related to
an incident or claim from being destroyed and disposed
of pursuant to a records destruction schedule.
29
Completing SFN 50508 Describing The
Location Of The Incident
Use any and all information to identify the location with
accuracy, including:
• the street address,
• city,
• area (sidewalk, parking lot, east entrance),
• building name,
• distance from building,
• highway and mile marker,
• etc.
30
Completing SFN 50508
Evaluation Of Whether An
Incident Could Have Been Prevented
This part of incident reporting gives the employee and his/her
supervisor the opportunity to evaluate the incident, to review how
it happened, and if something could have been done different.
Some factors to consider are:
Policies and procedures: which ones applied and were they being
followed? If not, explain why?
Do the policies and procedures need to be revised or updated?
Is there a need for additional training?
Is there an unsafe condition that needs to be corrected?
Do inspections need to be done more often?
This involves a “factual” analysis, rather than based on opinions.
31
Completing SFN 50508
Will Preventable Or Corrective
Action Be Necessary For Every Incident?
NO. There are incidents that are not preventable. However,
the possibility should still be explored for every incident. It
is also important to document and record whether
preventable or corrective action was taken or not. Further,
this automatically gives notification to Risk Management
that the incident was addressed by the entity.
When corrective action is needed, it is a good practice
and documentation to immediately complete a work
order and attach a copy to the incident report.
32
Completing SFN 50508/51301 What To Include In
The General Comments
Any facts or additional information that you know about the
incident. Diagrams may be applicable, if pictures are taken it can
be noted here that they will be attached or e-mailed, the weather
conditions that existed or conditions of the location (icy/slippery,
wet, snow covered), observations about the potential claimant
(running, slippery shoes, carrying large box), etc.
Example:
“I did not see the incident, but I spoke with Jane Doe within ½ hour
of her slipping on the sidewalk. She was wearing no-grip, high-
heeled shoes. She told me . . . Attached you will find the pictures
taken . . . “
33
Completing SFN 50508/51301
What Can I Expect After
The Reports Are Completed?
When the report forms are completed and submitted on-line, the
entry user will get an e-mail confirming that they have submitted
the report. The entity’s Risk Management Contact will also
receive an e-mail, along with a file attachments of the report.
Risk Management may contact you for more information or to
discuss the incident.
Other parties, such as insurance companies and attorneys, may
also contact you for information. If so, refer them, their questions,
or documents to the Risk Management Division. You should not
release information about the incident unless authorized by Risk
Management.
34
How Can I Be Sure Risk Management
Receives The Reports That I File?
In addition to e-mail notifications from the on-line system, Risk
Management sends monthly claim reports AND quarterly
incident reports to the entity’s Risk Management Contact.
If Risk Management has received the reports, the incidents will
appear on one of the loss run reports.
The reports should be reviewed by the Contact and compared
with the reports submitted to Risk Management.
If an incident is not on a loss run report, the Contact needs to notify
Risk Management.
Once it appears on a loss run, the entity’s copy of the report should
be destroyed.
35
Importance Of Cross-checking The Filing Of
Reports With The Monthly Loss Runs
Sent By Risk Management
Potential claimants have only 180 days from the date of
their incident to file their official Notice of Claim with
the Risk Management Division. If the reporting entity
does not ensure that the Reports have been received by
Risk Management, the 180 day time period can lapse
and the claimants may lose their opportunity to file a
claim with the State for their loss.
In this situation and if it was a valid, payable claim, not
only is it bad public policy and relations, the entity may
decide to pay the claim out of their own budget as the
Fund would be barred from it.
36
Related docs
