CALIFORNIA STATE UNIVERSITY SACRAMENTO

Risk Management Services Vehicle Accidents

State Driver Reporting Procedures

Sacramento State (California State University, Sacramento), is self-insured for its motor vehicle liability insurance through a program administered by the State of California, Office of Risk and Insurance Management (ORIM}, California Department of General Services.

CSUS drivers must report ALL motor vehicle accidents (in CS US-owned vehicles, as well as those occurring in personal or rental vehicles while being driven on official CSUS (State) business by the following procedures:

1. Say nothing regarding the accident, except to the police, other state officers or employees, or an identified representative of the State's contract adjuster.

2. Call the police or 911 in the event of an injury accident. If the police request a copy of yourinsurance, and you are operating a state-owned vehicle, provide them this form. In accordancewith CVC 16021, state ownership of the vehicle establishes financial responsibility.

3. Report it to the Risk Manager as soon as possible, preferably the same day, but no more than 24 hours.

a. Accidents that occur on Friday, Saturday, or Sunday must be reported the followingMonday. Preliminary reports are to be reported by phone to the Risk Manager. If thereis no answer, leave a message with your name, department, number to be reached at, and a brief description of the accident

b. Contact Information:

i. Todd Dangott 916-278-7233 desk, 916-278-4359 fax,River Front Center 220, Zip 6145

ii. Sac State Police, 916-278-6000

4. If you are driving a University/State-owned vehicle, complete the "Accident IdentificationForm"(STD 269) before leaving the scene of the accident.

5. All drivers must complete a "Vehicle Accident Report" (STD 270) and the CSUS "Accident orIncident Report" within 24 hours and send it to the Risk Manager.

6. The supervisor of the driver will investigate each accident promptly and thoroughly and completea "State Driver Accident Review - Supervisor's Review" form (STD 274} and send it to the Risk Manager with five (5) days.

7. Any accident that results in any of the following conditions must be reported to the Risk Manager,(916-278-7233} or Human Resources (916-278-3522} within eight (8) hours:

a. Death b. A disfiguring injuryc. A dismembering injury [loss of any bodypart]d. Hospitalization of the University employee for 24 hours or more for other than

observation

Revised April 2020

REPORT OF INCIDENT OR ACCIDENT CALIFORNIA STATE UNIVERSITY, SACRAMENTO

Revised Aug 2019 version 3.0 EHS

This form must be submitted within 24 hours of receiving information of an incident to, Risk Management Services.

SECTION 1: UNIVERSITY RELATIONSHIP (SELECT ONLY ONE) Faculty Staff Student Employee Student Assistant Department: Student Auxiliary Contractor Visitor Volunteer Other _________________ Police Report Made YES NO

SECTION 2: INCIDENT TYPE

Injury Illness Vehicle Near Miss Dangerous Condition Exposure Incident Other _______________________

SECTION 3: INVOLVED/INJURED’S INFORMATION

First Name: Last Name: M.I.:

Street Address: City: State: Zip:

Phone: Email:

SECTION 4: INCIDENT DETAILS Note: If an accident occurred while driving on university business, you must also complete the Vehicle Accident Report form STD 270.

DESCRIBE THE INCIDENT (STATE ONLY THE FACTS).What was the person doing just prior to and at the time of the incident? What objects/conditions contributed to the incident?

If the incident resulted in an injury or illness, answer the following questions.

a) Describe injury and part of body affected. ___________________________________________________________________

b) Did the individual receive first aid only? YES NO

c) Did the individual receive medical treatment? YES NO

d) Was the individual hospitalized? YES NO

Name of Clinic: Physician: ___________________________ Phone Number: ________________

If this is a Sacramento State employee, what time did the employee begin their shift?: ________ a.m. p.m. N/A

a) Supervisor: __________________ Title: ________________________ Date/Time notified: ____________________

b) Did the individual immediately return to work? YES NO

Preparer’s Name and Title (Print) Phone Number Date

Date of Incident:

Time: AM/PM Location:

Multiple persons involved YES NO

Name(s) Witnesses:

"SAVE AS" to computer: fax copy to: (916) 278-2641 or email to: rms@csus.edu