Form Appendix A-2 - Montgomery County, Texas Incident/accident Report - 2015
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1
2APPENDIX A-2
Page 1 of 2
MONTGOMERY COUNTY, TEXAS
INCIDENT/ACCIDENT REPORT
*This report is not to be used to report a Workers’ Compensation injury.
Date of incident/accident (I/A): ____/____/_____
Time: ____:____am
pm
TYPE OF I/A:
Report only
Vehicle
Property
Injured Person
(Check all that apply)
Report filed: Yes
No
Pictures taken: Yes
No
Emergency services called: Yes
No
Was there a personal injury other than a county employee: Yes
No
Was Law Enforcement notified: Yes
No
Sheriff
Constable
Local Police
D.P.S.
NAME AND ADDRESS OF PERSON(S) INVOLVED:
County Employee?
1._________________________________________________________________________
Yes
No
2._________________________________________________________________________
Yes
No
3._________________________________________________________________________
Yes
No
4._________________________________________________________________________
Yes
No
Location where I/A occurred:
_________________________________________________________________________________
(park, building, department, street, parking lot, etc.)
Address where I/A occurred:
__________________________________________________________________________________
Street Address
City
State
Zip Code
NAME AND CONTACT INFORMATION OF WITNESS(ES):
(Use back of form if needed)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
DESCRIBE VEHICLE OR EQUIPMENT INVOLVED:
County Owned
Unit #
(include photos of damage)
1. _________________________________________________________________
Yes
No
_____
2. _________________________________________________________________
Yes
No
_____
3. _________________________________________________________________
Yes
No
_____
EXPLAIN IN YOUR OWN WORDS WHAT HAPPENED.
Include task being performed
(facts only)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Were corrective actions taken to prevent recurrence? Explain
___________________________________________________________________________________________
__________________________________________________________________________________________
Person making this report: ____________________________________________
Employee
Supervisor
Signature
Department: ____________________
Day-time Phone: ___________________ Date: ____/____/____
Call the Risk Management Department at (936) 760 - 6935 as soon as the incident/accident occurs.
This form must be completed and faxed to the Risk Management Department within 12 hours of the
incident/accident. Fax: (936) 760 - 6916
2015
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