Sisters of Providence Health System
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
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
3. Operating a company or personal vehicle on company business without a valid
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
8. Reckless driving - as defined by jurisdiction
Remedies: Employees violating 3-8 above may be subject to discipline up to and
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
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
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
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
• 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
BRIGHTSIDE FOR FAMILIES AND CHILDREN
West Springfield, MA
SUBJECT: TRANSPORTATION OF CLIENTS AND RESIDENTS
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
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.
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).
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
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.
Sisters of Providence Health System
Vehicle Check List
Power Steering Fluid
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:__________
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 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.
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.
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
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 Telephone: Work Telephone:
License #: State: Exp Date:
Other Driver’s Information:
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:
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: