Sisters of Providence Health System Administrative Policy Acute by chenmeixiu


									                               Sisters of Providence Health System

                                      Administrative Policy
                                    Acute Ambulatory Network
                                    Behavioral Health Network
                                      Senior Care Network
                                      Health System Office

SUBJECT:       Vehicle Safety Program

Catholic Health East (CHE) and its member organizations recognize their responsibilities to their
employees and to the public they serve regarding the use of motor vehicles during the conduct of
business. Our goal is to eliminate, reduce and control personal injuries and property damage. CHE
has establised a Vehicle Safety Program as its guide to all member organizations and employees
who maintain or operate company vehicles. The program also addresses driving a personal vehicle
on company business. All employees of CHE and its member organizations are charged with the
responsibility of ensuring that company vehicles are utilized in a prudent manner, one which adheres
to all motor vehicle statutes, laws and regulations.

These guidelines have been approved by the leadership of SPHS and should be adhered to by all
employees operating personal or company vehicles while on work time. SPHS and its member
organizations will comply with all federal, state and local laws and regulations regarding vehicle
safety and operation.

I.    Oversight Responsibility:

       •    Oversight responsibility for these guidelines is vested in the CHE Risk Management
            Services Department in conjunction with member organization’s Risk Managers and their
            risk management programs.
       •    As new guidelines are developed, or as changes occur, they will be distributed to member
       •    Questions, comments or ideas concerning the improvement of the CHE Vehicle Safety
            Program are encouraged from all member organizations and employees.

II.    SPHS Facility Responsibilities:

       The Vehicle Safety Program is beneficial in controlling employee driving activities and
       attitudes. Each member organization is expected to support and enforce vehicle safety
       procedures, policies and accident prevention measures as described in the program.

       A.      It is the responsibility of each member organization to:
               • Support its Safety Committee in the implementation and maintenance of the
                   Vehicle Safety Program
               • Involve, train and educate supervisory personnel whose responsibilities are
                   affected by this program.

               •   Involve and educate all employees who are affected by this Program. (Note:
                   where driving a personal or SPHS-owned vehicle is an essential job element, this
                   should be included in the job description)
               •   Emphasize the importance of this program and require participation and
                   cooperation from all supervisors and employees
               •   Provide annual driver’s training consistant with other SPHS Facility driver’s training

       B.      Ensure that employees driving SPHS owned vehicles have been properly
               oriented to new vehicles before they may operate them.

       C.      Administration of the Program: It is the responsibility of each member
               organization to implement and and administer the Vehicle Safety Program
               as outlined, and to provide information to the SPHS Risk Management
               Director when requested. This program is designed to be sufficiently
               flexible to meet individual needs and allows each member organization to
               set individual objectives while complying with the overall System objective
               of reducing accidents and injuries.

       D.      Monitoring Requirements – Driving a Company Vehicle: To evaluate the
               effectiveness of and compliance with this Vehicle Safety Program each
               department manager will maintain a safety record for all employees who
               drive a company vehicle in the course of employment or a personal vehicle
               as part of their daily work.

            Employee Safety Record (kept in the home department):

                         Driver Training Annual Review form.
                                                       Driver Training Annual Review – Attachment 2
                         Copy of the initial CORI Motor Vehicle License Check
                         Results of Motor Vehicle Report Annual Check (RMV record check will be
                         obtained annually by the employee)

III.   Driver’s Responsibilities Drivers are required to do the following:

       A.      Driver’s License - A person operating a company or personal vehicle on
               company business is required to have in her/his possession a valid driver’s
               license from the state in which they reside.

       B.      Transporting Patients/Residents – Transporting patients/residents will be
               done using only SPHS owned/leased vehicles. Exceptions: See Brightside
               addendum policy.

       C.      Accident Reporting - Drivers shall an immediately make a verbal report if
               they are in a motor vehicle accident while on company business (within 1
               hr of the accident) to their immediate supervisor. The written report must
               be completed by the employee and reviewed by the immediate supervisor
               prior to the end of the work day. A report is required in the event of any

             accident involving a company owned or leased vehicle or any personal
             vehicle being driven on company business.

      D.     Vehicle Accident Reporting – Attachment 3 & 4

      E.     Submit to (blood and breath) alcohol drug testing:

                 Within 1 hour of the accident the employee mus tsubmit to alcohol & drug
                 screening. Failure to submit to alcohol and drug screening will result in corrective
                 action up to and including termination.
                 Prior to the start of a position involving the operation of any company or personal
                 vehicle on company business.
                 If SPHS suspects the driver is using an illicit drug or is under the influence of
                 At the time of their annual driver training review.
                 If an employee tests positive in any situation , further action will be taken
                 according to the SPHS Corrective Action Policy.
                 Provide obtain a copy of their RMV report from the DMV to be presented to their
                 supervisor at the time of annual review. Employees will be reimbursed by their
                 department for the expense of providing the report.

      F.     Vehicle Safety

                 Employees who operate or who are passengers in a company vehicle are
                 responsible for reporting any vehicle malfunction to their immediate supervisor.
                 Driver shall comply with all applicable state motor vehicle laws and operating
                 regulations, vehicle registrations and state mandated inspections.
                 Drivers shall be accountable for the safe operation of and damages to the vehicles
                 they operate while on company business. This includes company owned and
                 leased vehicles and personal vehicles being driven on company business. Drivers
                 are responsible for daily vehicle inspections, for reporting any repair situation and
                 for routine vehicle care as per procedures provided by her/his department.
                                                               Vehicle Safety Checklist – Attachment 1
                 Before any vehicle is placed into motion by the operator, all passengers, including
                 the driver, shall have her/his seat belts and shoulder straps fastened.
                 All employees operating a company or personal vehicle on company business will be
                 required to comply with the Safe Driving Policies and Remedies of this Program.
                 Drivers shall notify supervisor or other designated administrator when taking
                 medication that could impair driving ability or when there is any condition which
                 could impair driving ability. Note: the driver need not disclose the specific medication
                 nor the condition involved.
                 Driver shall not transport any non-authorized passengers, i.e., hitchhikers

      G.     Personal Vehicle - All employees operating a personal vehicle, as part of
             their daily work will carry auto insurance on the vehicles as required by

IV.   Safe Driving Policies and Remedies: Each employee, within his or her area of responsibility,
      shall be accountable for carrying out this policy.

A.   The responsibility for carrying out this policy is assigned as follows:
     • All supervisors shall be responsible for evaluating employee compliance with this
        policy and assuring that the Vehicle Safety Program is implemented within their
        areas of control.
     • The Safety Committee at each member or organization shall be responsible for
        evaluating performance, monitoring compliance with the policy for that
        organization and providing necessary education and training.
     • CHE Risk Management Services has the responsibility to:
        (a) Assist member organizations by providing resources for education and
        (b) Assist member organizations in monitoring program effectiveness.

B.   Violations & Remedies: Remedies are intended as minimal responses to
     violations. Additional responses, up to and including termination may be
     employed if the safety of patients, clients, residents, co-workers and the
     public may be compromised and lesser remedies may not adequately
     address the specifc situations.

     1. Operating a company or personal vehicle on company business without wearing
         seatbelts and/or restraints.
     2. Failure to require passengers to wear seatbelts and or restraints while in a
         company or personal vehicle on company business.
     Remedies: Employees violating 1 & 2 above may be subject to discipline up to and
     including discharge.
     3. Operating a company or personal vehicle on company business without a valid
         driver’s license.
     4. Driving a company or personal vehicle on company business while using and/or
         impaired by alcohol or drugs as defined by jurisdiction or refusing to be tested.
     5. Failure to report an accident, misrepresentation of the facts concerning a collision,
         or withholding information concerning a collision while driving a company or
         personal vehicle on company business.
     6. Knowingly leaving the scene of an accident without notifying the appropriate
         authorities (if required) or providing required information to other parties involved
         while driving a company or personal vehicle on company business.
     7. Allowing non-authorized individuals to operate company vehicles except in
         emergency situations.
     8. Reckless driving - as defined by jurisdiction
     Remedies: Employees violating 3-8 above may be subject to discipline up to and
     including discharge.

             9. Other violations and associated points:
                          Citation for careless driving,
                          Accidents that result in a citation,
                          Other preventable accident; as determined by severity and using National
                          Safety Council definitions for presentability
                          Failure to report accidents within the time stipulated in this policy
                          Citation for speeding
                          Other moving violations
             Remedies: Employees violating 9 above may be subject to having their driving
             privileges revoked/suspended or may be subject to discipline up to and including

      C.     Reinstatement: Prior to reinstatement of driving privileges, the employee
             driver must complete a management approved driver training course. They
             must also be in compliance with the SPHS Substance Abuse Policy. Failure
             of the employee/driver to comply with these programs may result in
             termination of the employee/driver.

      D.     Reporting: It is the responsibility of the immediate supervisor and/or any
             employee to notify the facility Risk Manager of any violation of policy. The
             Risk Manager is responsible for reviewing all accident reports, accident
             interviews and Motor Vehicle Reports and for assisting in carrying out the
             appropriate remedies.

V.    Safe Driver Training: It is the home department’s responsibility to evaluate the
      employee’s compliance with this policy. Evidence of training shall become part of the
      personnel file of all employees who drive in the course of their duties.

      Each member organization will be responsible for reviewing all positions and functions which
      require driving in the course of duties and developing a driver safety training program
      specific to those needs. Training should include hands on instruction in all vehicles with
      which the driver is not experienced.

      Providing annual Driver’s Training is the responsibility of the faciliy’s manager/administrator.

VI.   Driver Selection: All employees who drive company vehicles will be required to meet
      specific requirements. These requirements can be expanded to include member organization
      requirements. All employees must adhere to all state, federal and local laws and regulations.
      A.     Employees must:

             1. Possess a valid driver’s license issued by the state where the employee resides
                and be at least 18 years of age (note: where vehicle leasing agreements require a
                minimum age of 21 years, the 21 year age requirement shall apply. Supervisors
                shall be responsible for notifying their employees that this lease condition exists.)

             2. Successfully complete a physical exam and any related preplacement testing.

              3. Be qualified to operate the specific type of vehicle.

              4. Employees are required to provide to their immediate supervisor notification
                 within 1 business day of any off duty driving violations. Failure to report will
                 result in corrective action up to and including termination.
       B.     In addition, Human Resources shall:

              1. Review past driving performance and work experience through previous employee
                 reference checks.
              2. Before hire, obtain a motor vehicle agency CORI record from each state in which
                 the employee holds a license and annually thereafter.
       C.     Commercial Motor Vehicles/Commercial Drivers Licenses: Federal Motor
              Carrier Regulations set specific requirements for drivers in these

              1. Gross vehicle weight rating or gross combination weight rating of 10,001 or more
                 pounds; or
              2. Vehicle is designed to transport more than 15 passengers, including the driver
                 CDL requirements must be met for vehicles in these categories:
              3. Has a gross combination weight rating 26,001 pounds or more, inclusive of a
                 towed unit with gross vehicle weight rating of more than 10,000 pounds; or
              4. Has a gross vehicle weight rating of 26,001 pounds or more; or
              5. Is designed to transport 16 or more passengers, including the driver.
       D.     A driver may not be hired or continue in a postion which includes driving
              personal or company vehicles while on work time if the driver’s
              accident/violation history in the past two years includes one or more of the
              following convictions:

                  •   Driving under the influence of alcohol or drugs
                  •   Hit and run
                  •   Failure to report an accident
                  •   Negligent homicide arising out of the use of a motor vehicle
                  •   Operating during a period of suspension or revocation
                  •   Using a motor vehicle for the commission of a felony
                  •   Opeating a motor vehicle without the owner’s authority
                  •   Permitting an unlicensed person to drive
                  •   Reckless driving
                  •   Speed contest
                  •   Evading a police officer

                  The above is not intended to be an exhaustive list of the infractions which may
                  effect the employment status of the individual. Each situation will be weighed on
                  a case by case basis.

VII.   Vehicle Maintenance – Company Vehicles: The driver or individual designated by the
       member organization shall be responsible for obtaining all necessary repair, routine vehicle

        upkeep as outlined in the manufacturer’s owner’s manual and state mandated periodic
        inspections. Vehicle maintenance should be included in each member organization’s
        preventive maintenance program as applicable. All vehicles shall be washed and cleaned,
        inside and out, at least on a monthly basis and be free of trash and debris.

        Each vehicle is to have posted the vehicle’s specific information such as routine maintenance
        schedule and towing instructions.

        A properly maintained vehicle will reap the following benefits:
        • Improved safety
        • Reduced driving failures
        • Minimal interruptions in schedules
        • Improved public image
        • Increased vehicle resale/trade in value

VIII.   Accident Reporting – Driving a Company or Personal Vehicle on Company Business: The
        following steps should be taken immediately after an accident.
        • Seek aid for the injured
        • Call the police and/or your supervisor
        • Obtain facts about other vehicles
        • Obtain facts about all parties injured
        • Obtain names and addresses of witnesses
        • Describe and diagram the accident
        • Do not discuss the accident, except with the police, the insurance carrier, or
             representatives of management
        • Submit to breath alcohol and urine drug testing.

        Breath alcohol and urine drug testing:

        Drivers will go to WorkWise Occupational Health for testing once the above steps have been
        taken but before returning to their department. When possible the driver will contact
        Occupational Health before arrival. Occupational Health is open Monday through Friday from
        8am to 4pm for testing. Drivers must report to the Emergency Department at Mercy Medical
        Center on alternate shifts and weekends.

        1. An SPHS Incident Report form will be completed in detail by the employee and reviewed
           with his/her supervisor. When utilizing this report, all available information should be
        2. The employee operating the vehicle and his/her supervisor shall report the accident to
           the auto insurance company, and provide a copy of the accident report to the SPHS
           Director of Risk Management.
        3. The supervisor shall provide the SPHS Director of Risk Management with a copy of the
           accident report. The following information should also accompany the written report:
           • Copy of police report
           • Copy of two (2) repair estimates

            •   Copy of the paid repair invoice (if the vehicle is a constructive total loss, e.g., repair
                and salvage bid equal market value) salvage bids and the final amount of the salvage
                must also be documented.
            •   Other incidental costs may be pertinent to your claim. Such things as towing, rental,
                damage to property other than the vehicle or medical expenses should also be
         Reporting – Personal Vehicle on Company Business. If a company employee is involved in a
         motor vehicle accident while operating a personal vehicle on company business, the accident
         should also be reported to the employee’s insurance company with a copy to the supervisor.
         The supervisor will provide copies to the facility risk manager and the SPHS Director of Risk

Dated:          September 18, 2003


Vincent J. McCorkle
President & CEO, SPHS

Plans, Program, Statements/Risk Management
Revisions:    November 2006


                                   West Springfield, MA

                                        Operational Policy


POLICY:       Whenever possible, clients and residents will be transported in vehicles owned or
              leased and operated by SPHS organizations. When the transport of clients or residents
              in employee-owned vehicles is expected in the scope of one’s employment
              responsibility, the position description shall reflect that requirement.

              DESCRIPTION OF TRANSPORTATION SERVICES: Brightside does not provide
              regularly scheduled transportation of students to or from their homes. Brightside does
              provide transportation within the scope of the programs services, this includes off
              campus activities, appointments and home visits. Students from Brightside’s community
              residences are moved to and from the campus by our vehicles.

              Brightside staff members are not “drivers.” The direct care staff members who drive the
              vehicles within the scope of their duties are licensed in accordance with state laws, are
              given vehicle in-service training and must pass background checks of their driving
              records and criminal history.

PURPOSE:      To avoid injuries and to insure the health and well being of clients, residents, and
              employees in the course of non-emergency transportation of clients and residents.


I.    Vehicle Maintenance – Refer to SPHS Vehicle Safety Program
      A. All Brightside registered vehicles, leased or owned:
         1. are inspected once a year in accordance with the Massachusetts Registry of Motor
             Vehicles regulations; and
         2. maintain the following equipment in, or on, the vehicle:
             a. First Aid Kit
             b. Pair of Chock Blocks
             c. Three flares
             d. Fire Extinguisher
             e. Front and rear flashing lights

II.   Transportation Guidelines for all Vehicles – Refer to SPHS Vehicle Safety Program
      A. Employee/Volunteer/Intern (Employee) Responsibilities
         1. Residential, TA, Supervisory and Management staff employees:
            a. All employees must provide two copies of their current drivers license, one to the
                Human Resources Department and one to their department manager or designee.
                • Department manager or designee will then notify Environmental Services that the
                    employee is eligible to drive as required by their department.
                • Environmental Services Director, or designee, will then update the insurance
                    company listing of drivers and notify the switchboard and the Support Services
                    representative of the changes.
                • Human Resource Department will obtain and keep a record of employee’s driving
                       Two months prior to license expiration date, Human Resource Department
                       will notify department head or designee of staff that are due for license
                       Department manager will follow up with the employee and send a copy of
                       renewal to the Human Resouce Department
   2. All employees who transport clients and residents shall:
      a. Ensure the following safety measures:
          • No smoking is allowed in all Agency vehicles.
          • No use of car phones or walkman-type or any electronic device with headphones.
          • No eat or drink in vehicle while it is in motion.
B. Accident Reporting – Refer to SPHS Vehicle Safety Program
   1. In the event of an accident involving an employee/volunteer/intern operating a vehicle
      being used to transport clients and residents, the driver shall provide a report by following
      these steps:
      a. Immediately contact the local police to file a report
      b. Contact the Campus Administrator to inform her/him of the accident.
      c. A telephone report to the employee’s supervisor must be made within 1 hour.
          • Accidents involving a fatality or injury must be immediately reported to the
              employee’s supervisor and Brightside Risk Manager.
      d. The Accident Information Form (Addendum 4) must be completed before end of shift
          and forwarded to the Environmental Services Director.
      e. The Environmental Services Director will inform the SPHS Director of Risk
          Management and the automobile insurance carrier of reported accidents.
      f. The driver or supervisor must complete a Brightside Critical Incident Form(s) before
          leaving their shift. This form will be collected by the Campus Administrator who will
          place it in the mailbox of the Quality and Risk Manager before leaving shift.
      g. If the accident occurred with residents in the vehicle, the Campus Administrator must
          immediately notify each residents’ legal guardian and all internal Departmental
          Directors and external agencies (eg., D.S.S., D.C.F., DEEC, DOE). Clients in the
          vehicle must be checked by medical personnel.

C. Training
   1. All employees who transport clients/residents in any Brightside vehicle shall undergo a
       basic orientation prior to the first such use of a vehicle.
       a. Training will be conducted by the Coordinator of Staff Development and Education, or
           designee, and shall include:
           • classroom instruction during the Orientation period
           • specific vehicle orientation for a minimum of thirty (30) minutes in length and
               contain, at a minimum, a review of the guidelines in this policy
           • a driving test
           • annual driving review each year following orientation
           • and written documentation of test results.
       b. Records of driver training shall be placed in the employee’s personnel file and
           maintained for five (5) years.
       c. Should a medical situation arise (seizure, bee sting, allergic reaction), all residential
           employees are trained in First Aid and CPR.
           • Staff will assess the situation, call for assistance (i.e. Campus Adminstrator or
               Agency nurse) and remain with the client until proper medical help arrives or
               instruction is received.
D. Use of Personal Employee Vehicle
   1. The use of employee-owned vehicles for the non-emergency transportation of clients and
       residents may occur only if an agency vehicle is not available at the time of transport and
       with the prior approval of the Department Head.

           2. When a personally owned vehicle is used, the employee/volunteer/intern is responsible to
              provide to the Unit Manager/Program Director (a copy should be placed in the Personnel
              file), on an annual basis, the following:
              a. Proof of current driver’s license.
              b. Current valid state vehicle inspection sticker
              c. Proof of current registration and insurance of vehicle
              d. Proof of coverage for additional passenger (when the transportation of clients and
                   residents in the employee’s vehicle is an expected function of an employee’s position
                   and occurs on a regular basis, the employee is advised to so notify his automobile
                   insurer and obtain additional passenger coverage).

Revised 9/25/06

                                            Driver’s Test
Name: _____________________________________________________ Date: _________________

Please check the correct answer in the following multiple-choice questions:

1. Compared to a passenger car, a van’s following distance should:
         be greater, but only in adverse weather.        never be more than three seconds.
         be the same.                                    be greater in both ideal and adverse

2. Properly adjusted mirrors will:
           eliminate all blind spots.                      reduce your blind spots.
           eliminate all side collisions.                  make you more visible to other drivers.

3. Vans differ from passenger cars in all of the following ways except that vans:
           usually have a higher center of gravity.          usually have larger blind spots.
           are usually more affected by crosswinds.          usually have shorter stopping distances.

4. Average reaction time is:
          3-5 seconds                                      3 seconds
          ¾ of a second                                    4 seconds

5. During your pre-trip inspection, you should check:
           lights and mirrors.                             windshield wipers and washer fluid.
           tire pressure and tread depth.                  all of the above.

6. While on the road, you should check your mirrors:
          every 3-5 seconds.                               every quarter mile.
          every 12-15 seconds.                             every 3-5 blocks.

7. When you must back your van, it is best to:
         avoid using a spotter.                            back to the driver’s side whenever possible.
         place the spotter in the path of the van.         back to the passenger’s side whenever

8. Hydroplaining:
          is rarely a problem because vans are heavy.
          will not occur if your tires are properly inflacted and have proper tread depth.
          can occur at any time the roadway is wet and at speeds as low as 30 miles per hour.
          occurs only in heavy rains and at high speed.

9. In adverse weather:
           stopping distances are greater.                 following distances shouldn’t change.
           stopping distances are the same.                following distances should be less.

10. When driving on the highway, you should scan:
         every 3-5 seconds.                                one mile down the road.
         12-15 seconds down the road.                      only to the next vehicle.

11. When driving in the city you should scan:
         every 3-5 seconds.                                only to the vehicle ahead.
         1 to 1½ blocks ahead.                             Scanning in the city is not recommended.
12. When stopped at an intersection, you should do all of the following EXCEPT:
         stop behind the stop line.                            stop before the crosswalk.
   back up immediatley if you stop in the                leave space between you and the vehicle ahead.

13. If a jaywalker is waiting to cross the street at mid-block, you should:
            cover the brake to be ready to stop if the pedestrian crosses in front of you.
            stop and let the pedestrian cross in front of you.
            stop and wave the pedestrian accross, but only when you are sure all other traffic is stopped.
            put on your hazards lights to warn other drivers, then allow the pedestrian to cross.

14. When using a helper to back, which of the following statements is NOT correct?
         Make sure the helper is out of the backing path and visible in your mirror.
         Agree on hand signals before backing.
         Roll down your window and turn of fall radios so you can hear any warnings.
         It is the helper’s responsbility to make sure you back safely.

15. While driving, you should:
          lean in your seat to reduce the size of your blind spots.
          adjust your seat forward or back to redue the size of your blind spots.
          place clipboards, important papers or radios on the engine cover so you can reach them
          None of the above.

16. Safety belts:
           aren’t necessary to war if not required by your organization.
           are recommended for the dirver and all passengers.
           are optional when transporting cargo.
           are effective in reducing injury only in high-speed crashes.

17. When driving in the rain or other adverse weather conditions.
         you should increase your following distance.
         it is safe to travel at the posted speed limit.
         you should brake harder to compensate for the increase in stopping distance.
         you should drive as you would in ideal conditions.

18. When driving at night, it is recommended that you do all of the following EXCEPT:
         Look to the right edge of the road to avoid being blinded by headlights from an oncoming
         Reduce your speed.
         Use your high beams whenever safe and legal to do so.
         Immediately pass erratic drivers who may be impaired.

19. In ideal conditions, it is recommended that you follow no closer than ________ behind the vehicle
           2 seconds                                        4 seconds
           3 seconds                                        two vehicle lengths

20. While waiting to make a left turn at an intersection:
          wait with your wheels straight
          wait with your wheels turned in the direction you want to go.
          wait with your foot over the accelerator to reduce your reaction time so you can shoot through
           a small break in traffic.
          try to time the light change by concentrating on the traffic light.

                                           Attachment 1
Sisters of Providence Health System
Vehicle Check List
DATE: _______________
Inspection Due:
Mileage:       Present:
Brake Fluid:
Transmission Fluid:
Power Steering Fluid
Accident Packet:

                                                                                                          Attachment 2
                                Driver Training Annual Review

Employee: _______________________ Facility/Dept:_____________
License Number:__________________State issuing license:_______Date of Birth:____

Written Driving Test                        PASS             FAIL              Date of Test:_____________

Driving Road Test                           PASS             FAIL              Date of Road Test:_________

Drug testing                                PASS                Date of Test:__________
                                                                        YES    NO
1.      Inspects the exterior and interior of the vehicle for damages, etc.

2.      Documents use of vehicle and any deficiencies/problems noted.

3.      Checks wipers, first aid kit, and fire extinguisher.

4.      Checks directional lights and uses effectively on the roadway.

5.      Adjusts mirrors and seating properly before driving.

6.      Driver insures self and all passengers wear safety belts.

7.      Driver backs up scanning area around vehicle.

8.      Adheres to posted speed limits, constantly scanning the roadway.

9.      Driver checks mirrors every 3-5 seconds including blind spots.

10.     Allows a cushion of safety and maintains safe following distance.

11.     Driver yields to pedestrians and covers the brake where necessary.

12.     Demonstrates proper parallel parking and keeping wheels straight.

13.     Changes lanes using directional’s, while avoiding potential hazards.

14.     Driver demonstrates awareness of tailgating for self and others.

15.     Demonstrates proper procedures for right-turn-on-red signals.

Instructor Comments:

Instructor signature: ___________________________                              Date: ___________
Instructions: This form must be completed for each employee who drives as a part of their work. A copy will be forwarded to
the home department manager to be maintained in the employee’s educational file. Annual Dept of Motor Vehicle checks will
be obtained annually by the Human Resources Department.
                                                                                                 Attachment 3
                            SPHS Vehicle Safety Program
             What to do if you are in an Auto Accident at work
       When there is an auto accident the employee and their immediate supervisor/manager are
responsible for reporting this event to the insurer and notifying the SPHS Director Risk
Management (T. Cole-Poklewski). The sooner you report an incident the sooner you can obtain the
estimates and repairs needed. Unlike general/professional liability the reporting to the insurer is the
responsibility of the department that has the loss NOT the SPHS Director Risk Management.
       If you have any questions please call me at 748-9095.

Employee Responsibilities (Driving a Company or Personal Vehicle on Company Business)
The following steps should be taken immediately after an accident.
        Seek aid for the injured
        Call the police and/or your supervisor
        Obtain facts about other vehicles, all parties injured
        Obtain names and addresses of witnesses
        Describe and diagram the accident
        Do not discuss the accident, except with the police, our insurance carrier (ACE or ESIS),
        or representatives of management.
Immediately upon returning to the facility the following steps should be taken.
        Employee completes the SPHS Vehicle Accident Report (Attachment 1) with all information
        gathered at the time of the accident. Give the incident report to your immediate supervisor for
        reporting to the insurance company.

Supervisor Responsibilities
       Review SPHS Vehicle Accident Report with employee; document your investigation & action
       taken on the Report.
       Notify the Insurance Company of the accident, when the SPHS Vehicle Accident Report is done
       by calling 1-888-832-3747 and tell the nice person all the details she asks for. Your facility is
       insured as Catholic Health East/Sisters of Providence Health System. You may need to clarify
       that you are calling from one of many facilities under the CHE/SPHS network. If you tell them
       anything about the accident in addition to what is on your Vehicle Accident Report, please also
       put that information on the form. The agent on the phone will give you a report number and will
       tell you where the adjuster is coming from and what their phone number is. Please also add this
       to the report wherever there is space.
       When you hang up, immediately fax the form to the SPHS Risk Management at 413-748-9399
       and keep the original for your records. The adjuster will call to arrange a visit or will just come by
       to see the vehicle.
       VERBAL notification - The supervisor is responsible for notifying T.Cole-Poklewski of the
       incident (telephone call 748-9095, voicemail, or email) within 8 hours of incident.
       WRITTEN notification – The supervisor is responsible for sending a complete copy of all
       information sent to insurer to T.Cole-Poklewski for inclusion in the SPHS auto claim file – within
       24 hours of the incident.
Note: If a company employee is involved in a motor vehicle accident while operating a personal vehicle
on company business, the accident should also be reported to the employee’s insurance company with
a copy to the supervisor. The supervisor will provide copies to the facility risk manager and the SPHS
Risk Manager.

                                                                                                           Attachment 4
                                    SPHS Vehicle Accident Report
   Date of Accident:                                                      Time:                                AM    PM
SPHS Vehicle Information:
   License Plate #:                                        VIN #:
 Year:                    Make:                     Model:                                            Color:

     Description of Damage:         Check here if “None”

SPHS Driver Information:
  Driver’s Name:                                                                       Date of Birth:
     Facility where employed:                                                        Dept:
   Home Address:
   Home Telephone:                                                  Work Telephone:
  License #:                                                     State:                        Exp Date:

Other Driver’s Information:
  Home Address:
Home Telephone:                                                 Work Telephone:

Other Vehicle Information:
   License Plate #:                                        VIN #:
 Year:                    Make:                     Model:                                            Color:

     Description of Damage:         Check here if “None”

         If additional cars are involved put the information required above for each on the back of this form.

Description of Accident:        Check here if damage was discovered while doing a vehicle pre-trip inspection.
Location of Accident:
What happened?

SPHS Vehicle Policy states that drug and alcohol screen testing be performed within an hour after the accident.
Was drug and alcohol screen testing performed?
Occupational Health    Mercy ER       Other   ______________________________

                   Driver’s Signature:                                             Supervisor’s Signature
                                                  For Supervisor Only:
 Report #:                                                                        Date/Time Called:


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