PERSONNEL ADMINISTRATIVE MANUAL

Topic:               COUNTY-WIDE INCIDENT REPORTING                                                                                      (Non-employee)                                                                     Date Issued: June 23, 1994

Section:            LIABILITY/PROPERTY                                                                                                                          INSURANCE PROGRAM                                                Date Revised: March 29, 2013

Number:            XXIII.11

PURPOSE:

To establish county-wide procedures for reporting of non-employee related incidents.

POLICY:

It is the policy of the County of Santa Cruz that all incidents of potential liability shall be reported to the Risk Management Division of the Personnel Department.

PROCEDURE:

1.   Employees who either witness or are on the scene of a non-employee injury incident shall ask the injured person if they want medical treatment or if appropriate call "9-911." Be prepared to provide the 911 dispatcher with the exact location you are calling from, the location of the injured person, and a description of injuries.

EXAMPLE: I'm calling from the Personnel Department, 3rd Floor of the Governmental Center, 701 Ocean Street. A woman slipped and fell in the hallway in front of my office and hurt her leg.

DO NOT offer the County to pay for medical treatment or transportation. Refer all questions, comments and concerns about the incident to the Liability/Property Program Manager in Risk Management.

If possible, notify Risk Management of the incident. The Liability/Property Program Manager will want to assess the site for potential County liability.

2.   Get the name, address, phone number and as many details as possible of the person and circumstances. GET NAME AND PHONE NUMBER OF WITNESSES.

3.   Complete the County of Santa Cruz Incident Report - PER5012 immediately, SAME DAY, while the details of the incident are fresh in your memory.

4.   Forward the completed form PER5012 to Risk Management within 24 hours of the incident.

5.   Refer all questions, comments and concerns about the incident to the Liability/Property Program Manager.

SEE NEXT PAGE FOR FORM PER5012

COUNTY OF SANTA CRUZ INCIDENT REPORT (Non-employee)

Date of Incident:_______________________________ Time of Incident:__________________________

Injured's Name:_______________________________________________________________________

Address:____________________________________________________________________________

City/State:__________________________________________ Phone No.________________________

Exact Location of Incident:______________________________________________________________

Description of Incident (use back if more space needed):______________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Conditions at site: (wet, dry icy, etc.)______________________________________________________

Did Police Respond: __ Yes __ No If yes, Name and Agency___________________________________

Medical Attention Required: _____ Yes _____ No

If yes, what type and which facility:________________________________________________________

___________________________________________________________________________________

Property Damage: _____ Yes _____ No

If yes, describe:______________________________________________________________________

___________________________________________________________________________________

Witnesses: Name, Address and Phone Number

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

Report Completed By:____________________________________ Date:_____________

FORWARD COMPLETED REPORT TO RISK MANAGEMENT WITHIN 24 HOURS OF INCIDENT