# SUBJECT: Accident Reporting, Investigation, and Review

1\. **[PURPOSE]{.underline}**: This memorandum establishes policies, and
procedures to follow in the reporting, investigation and review of
on-the-job injuries and job-related illnesses that result in lost time,
light duty, and medical treatment.

2\. **[POLICY]{.underline}**: To control and if possible, eliminate
factors, which may lead to employee accidents and illnesses.

3\. **[DISCUSSION]{.underline}**: Accident prevention must be diligently
followed by all employees in order to reduce injuries/illnesses which
may result in lost time, light duty, or medical treatment to employees,
visitors, and contractors. The best way to accomplish this is to
identify and alleviate the cause(s) of injuries/illnesses which result
in lost workdays.

4\. **[GENERAL CONCEPTS]{.underline}:**

a\. An injury or illness is considered work related if it results from
an event of exposure in the work environment. The work environment is
primarily composed of: 1) The employer\'s premises, and 2) other
locations where employees are engaged in their employment. When an
employee is off the employer premises, work relationship must be
established; when on the premises, this relationship is presumed. The
employer\'s premise encompasses the total establishment. This includes
not only the primary facility, but also satellite cemeteries. In
addition to physical locations, equipment or materials used in the
course of an employee\'s work are also considered part of the
employee\'s work environment.

b\. All work-related fatalities are recordable.

c\. All recognized or diagnosed work-related illnesses are recordable.

d\. All work-related injuries requiring medical treatment or involving
loss of consciousness, restrictions of work or motion, or transfer to
another job are recordable.

5\. **[DEFINITIONS]{.underline}**:

a\. **[Accident]{.underline}:** Any untended or unplanned occurrence
that results in an injury to personnel, visitors, members of the public,
property damage, production interference, or a combination of these
conditions.

b\. **[Employee]{.underline}**: Any person who receives pay from the
NCA, other than on contract basis, for service rendered.

c\. **[Member of the Public]{.underline}**: Any person who is injured
while on NCA premises or as a result of a motor vehicle accident
involving an NCA-operated motor vehicle. In addition to visitors, this
includes voluntary workers, personnel who work without compensation,
employees of other federal agencies, and employees of NCA contractors.

d\. **[Motor Vehicle Accident]{.underline}**: Any occurrence involving a
government-owned, leased or rented vehicle, or privately owned vehicle
while operated on official NCA business which results in death, injury
or property damage.

e\. **[Occupational Injury]{.underline}**: An injury to an employee such
as a cut, fracture, sprain, amputation, etc., which results from a work
accident or from exposure in the environment.

f\. **[Occupational Illness]{.underline}**: Abnormal condition or
disorder sustained by an employee, other than one resulting from an
occupational injury, caused by exposure or environmental factors
associated with employment. It includes acute and chronic illnesses or
diseases which may be caused by inhalation, absorption, ingestion or
direct contact.

g\. **[Tort Claim (Dollars)]{.underline}:** Any wrong resulting from an
occupational accident other than a breach of contract for which the law
allows recovery.

h\. **[First Aid Treatment Case]{.underline}**: One-time treatment and
subsequent observation of minor scratches, cuts, burns, splinters, and
so forth, which do not ordinarily require additional medical care, even
though provided by a physician or registered professional personnel.

i\. **[Lost Work Days]{.underline}:** Days the employee would have
worked but could not because of occupational injury or illness. The
number of lost workdays does not include the day of injury but does
include all days (consecutive or not) on which, because of the injury or
illness, the employee would have worked but could not.

j\. **[Medical Treatment Case]{.underline}**: Any occupational injury or
occupational illness for which treatment is administered by a physician
or by registered professional personnel under the standing of a
physician. Medical Treatment Case does not include \"Employee
Fatality\", \"Lost Work Day Case\", or \"First Aid Treatment Case\", as
defined above.

6\. **[REPORTING OF ACCIDENTS & MEDICAL ATTENTION]{.underline}:**

a\. **[Referral to VA Medical Center's Occupational
Health]{.underline}**: Any employee, volunteer or visitor incurring any
injury as a result of an accident will be referred immediately to the
servicing VA Medical Center's Occupational Health for medical attention.

b\. **[Responsibility of VA Medical Center's Occupational
Health]{.underline}**:

1\. Upon referral of an injured employee, volunteer, or visitor, the
Occupational Health Nurse or the Personnel Health Physician will examine
and determine the extent of injury and provide treatment.

2\. Unless the accident or injury is minor or unlikely to recur, VA
Medical Center's Occupational Health will notify the VA Medical Center's
Occupational Safety and Health Section.

3\. Upon examination and/or treatment of an employee, Occupational
Health will complete VAF 5-3831b following instructions on the form, and
notify employee\'s supervisor of disposition. They will determine and
advise the injured employee's supervisor of the medical feasibility of
the employee returning to his or her duty assignment or possible
temporary light duty assignment.

c\. **[Responsibility of the VA Medical Center's Occupational Health
Nurse (OHN)]{.underline}:**

1\. OHN will perform injury assessment and treatment as indicated.

2\. Follow-up when indicated for injury, accident prevention, and/or
rehabilitation.

d\. **[Accident Investigation]{.underline}**:

1\. Any accident that might result in lost time, light duty, or serious
injury will be investigated immediately by the supervisor of the injured
employee, the VAMC Safety Specialist and the injured employee (if able).
Any pertinent supporting data such as witness statements, employee
descriptions, and suggestions for correction must be obtained at this
time. Attachment A provides guidelines for an accident investigation.

2\. An accident investigation should also be initiated if the accident
meets any of the following criteria:

a\. If the accident was caused by an environmental hazard.

b\. If there is potential for another employee to be injured the same
way.

c\. If it is apparent from the injury that there might be lost time.

d\. If there was exposure to any known hazardous substance.

e\. When circumstances surrounding the accident are unclear.

f\. Back injury; and

g\. Vehicle accident.

**e.** **[Responsibility of Supervisor of Injured
Employee]{.underline}**:

1\. Enter a complete and accurate report of the accident/illness (VA
Form 2162 -- Report of Accident) on the National Cemetery
Administration's Internal Web Site -- Inspection Tracking System (Add
Accident Report) within 48 hours of the accident. Where NCA
property/vehicle damage is involved, notify local police authority for
an accident investigation and prepare VA Form 90-1217 (Report of
Survey). Submit VA Form 90-1217 to the Accountable Official. Enter the
employee's injury in the Occupational Safety and Health Administration
(OSHA) Log.

2\. Conduct an investigation and provide corrective action within four
working days of the accident. Take necessary corrective and preventive
measures to alleviate a recurrence of this type of accident. A thorough
investigation will determine one or more causes of the accident and
appropriate management action will be taken either by correcting an
unsafe condition or an unsafe practice by an employee or a combination
of both elements.

3\. Review employee\'s records for physical disability limitations,
accident proneness, or any other significant factor that may have
directly or indirectly caused the accident.

4\. Follow through on each injured employee\'s case until all necessary
actions have been completed.

5\. Inform the employee of their option to complete a CA-1 or CA-2.
Ensure the employee is provided a printout, or has access to print out
the CA-1 or CA-2 form (if requested). Signed CA-1 and CA-2 forms must be
forwarded to the OWCP Coordinator (05) & MSN IV Safety Officer.

6\. Notify District Counsel of any accident that may result in a tort
claim against the Government.

f\. **[Visitor Accidents]{.underline}**: Notify District Counsel of any
visitor accident that may result in a tort claim against the Government.
Enter a complete and accurate report of the accident/illness (VA Form
2162 -- Report of Accident) on the National Cemetery Administration's
Internal Web Site -- Inspection Tracking System (Add Accident Report)
within 48 hours of the accident. Where NCA property/vehicle damage is
involved, notify local police authority for an accident investigation
and prepare VA Form 90-1217 (Report of Survey). Submit VA Form 90-1217
to the Accountable Official. Notify MSN IV Director, MSN IV Safety
Officer and VAMC Safety Officer of the visitor's accident. Visitors
involved in accidents will be immediately referred to VA Medical
Center's Occupational Health. The supervisor who is responsible for the
area is also responsible for initiating an investigation and notifying
the VA Medical Center's Occupational Safety and Health Section so that
interviews can be completed at once with the visitor and any witnesses.

g\. **[It is the responsibility of all employees]{.underline}:**

1\. To report accidents, injuries, and illnesses to their supervisors.

2\. To report to VA Medical Center's Occupational Health for first aid
or medical treatment for all injuries, even if minor. Employees must
report to VA Medical Center's Occupational Health for evaluation of on
the job injuries prior to seeking treatment from their personal
physician.

3\. To submit signed notice of injury through Form CA-1, or of disease
of illness on Form CA-2 to their supervisor. Signed CA-1 and CA-2 forms
must then be forwarded to the OWCP Coordinator (05) & MSN IV Safety
Officer.

4\. **Accidents involving vehicles**: Do not move damaged
property/vehicles until inspected by your immediate supervisor and
completion of the local police authority accident investigation.
Immediately make an oral report to your immediate supervisor of damage
to property/vehicle. Furnish proper identification to persons directly
involved in the accident. Fill out Standard Form 91 (Operator's Report
of Motor-Vehicle Accident) while at the scene of a motor vehicle
accident.

h\. **[Accident Report Forms and Reporting]{.underline}**:

1\. **[VA Form 5-3831c:]{.underline}** \"Daily Report of Employee\'s
Injuries,\" will be prepared by the Employee Health Unit and a copy
forwarded to the VA Medical Center Safety Specialist as soon as possible
after initial visit of the employee to the health unit.

2\. **[Report of Accident (VA Form 2162):]{.underline}** Enter a
complete and accurate report of the accident/illness on the National
Cemetery Administration's Internal Web Site -- Inspection Tracking
System (Add Accident Report) within 48 hours of the accident. Where NCA
property/vehicle damage is involved, notify local police authority for
an accident investigation and prepare VA Form 90-1217 (Report of
Survey). Submit VA Form 90-1217 to the Accountable Official. Enter the
employee's injury in the Occupational Safety and Health Administration
(OSHA) Log. CA-1, Notice of Traumatic Injury and Claim for Continuation
of Pay/Compensation and CA-2, Notice of Occupational Disease and Claim
for Compensation are required to be printed and signed by the employee.
Signed CA-1 reports must be sent to the OWCP Coordinator (05) & MSN IV
Safety Officer within ten (10) workdays following receipt of the form
from the employee. Signed CA-2 reports must be sent to the OWCP
Coordinator (05) and MSN IV Safety Officer within five (5) workdays
following receipt from the employee.

3\. **[Members of the Public - Fatal and Non-Fatal
Accidents]{.underline}**: Enter a complete and accurate report of the
accident/illness (VA Form 2162 -- Report of Accident) on the National
Cemetery Administration's Internal Web Site -- Inspection Tracking
System (Add Accident Report) within 48 hours of the accident.

4\. **[Motor Vehicle Accident]{.underline}**: Immediately make an oral
report to your immediate supervisor of damage to property/vehicle.
Notify local police authority for an accident investigation. Do not move
damaged property/vehicles until inspected by your immediate supervisor
and completion of the local police authority accident investigation.

a\. A motor vehicle accident is any occurrence involving a
government-owned, leased, or rented vehicle, or privately owned vehicle
while operated on official NCA business, which results in death, injury,
or property damage regardless of who was injured or what property, was
damaged. In the event of a motor vehicle accident, the operator of the
vehicle will complete the SF-91, \"Operator\'s Report of Motor Vehicle
Accident\", at the scene of the accident, and submit it to the
supervisor. The operator\'s supervisor will enter a complete and
accurate report of the accident/illness (VA Form 2162 -- Report of
Accident) on the National Cemetery Administration's Internal Web Site --
Inspection Tracking System (Add Accident Report) within 48 hours of the
accident. Forward the SF-91 to the VA Medical Center Safety Specialist
for review and disposition within 48 hours from date of accident.

b\. The SF-91 and SF-94, Statement of Witness, are included in a packet
in the glove box of all GSA vehicles. Other forms such as SF-91A,
Optional Form 26, and \"Motorists Report of Motor Vehicle Accident\"
Form SR-1 need to be completed by the supervisor and the vehicle
operator if applicable.

c\. If a motor vehicle accident occurs on NCA property, VA Security
Police will be contacted. If the motor vehicle accidents occur off VA
property, the applicable law enforcement agency will be contacted (i.e.,
City, State or County police, etc.) for investigating and reporting. A
copy of this report will also be sent to the VA Medical Center Safety
Specialist and MSN IV Safety Officer.

d\. Whenever possible and practical, photographs of the motor vehicle
accident should be taken.

e\. **[Driver\'s Liability Act]{.underline}**: In addition to the above,
a further protection is offered to employees (under certain
circumstances) under the Driver\'s Liability Act.

\(1\) An employee who may be sued because of damage, injury or death
resulting from operating a motor vehicle while acting within the scope
of employment may be relieved of responsibility for claims for damages.

\(2\) When an employee is involved in an accident while operating a
motor vehicle on official government business; and that incident results
in property damage, personal injury or death to other persons, the
following action must be initiated:

\(a\) A detailed notarized affidavit concerning all aspects of the
incident from the employee and his/her supervisor must be forwarded to
the VA Medical Center Safety Specialist & MSN IV Safety Officer within
10 working days of the incident.

\(b\) The VA Medical Center Safety Specialist will submit copies of the
affidavits to the Network Safety Manager. A copy of the entire file will
be kept in OS&HS.

\(3\) In the event an employee is sued for damage to property, or for
personal injury or death, due to his/her operation of a motor vehicle in
the performance of duty, the reports and affidavits on file may be
critical in future litigation.

\(4\) While the Driver\'s Liability Act provides certain protection
against suits, it does not provide protection in all circumstances.
Employees who operate government motor vehicles (or privately-owned
vehicles on government business) would be well advised to consider
carrying private liability insurance to cover those situations in which
the employee may not be afforded the protection of the Driver\'s
Liability Act.

7\. **[REFERENCES]{.underline}**: NCA Directive 7700, NCA Handbook 7710,
Safety Requirements for VA National Cemeteries, VA Handbook 7125, Office
of Acquisition and Materiel Management -- Report of Survey.

8\. **[REVIEW DATE]{.underline}**: January 2004.

George M. Webb

MSN IV Director

Attachment

Distribution

Cemetery Directors

Safety Officers

Supervisors/Foreman/Work Leaders

**Attachment**

## ACCIDENT INVESTIGATION

## POSSIBLE LOST-TIME, LIGHT DUTY ACCIDENT INQUIRY

1\. Each employee should be reminded that the supervisor must be
notified immediately when a work related accident/injury occurs. Work
illnesses must also be promptly reported, but are more difficult to
pinpoint as to the time.

2\. The supervisor, when notified of an injury, will visit the scene of
the accident with the injured party if possible. A staff member from the
Occupational Safety and Health Section will be notified so that they can
assist with the accident inquiry in those cases where lost-time, light
duty, or serious injury may be involved. The supervisor will:

A. Visit the scene

B. Talk to witnesses

C. Obtain assistance

D. Recommend corrective action

E. Be prepared to follow up with the injured employee

3\. Witnesses are the supervisor\'s best source of information about an
accident. Anyone who knows something of the incident may contribute
valuable information or the name of someone else that can provide it.

4\. Witnesses will be interviewed one at a time and as soon as possible
since memories fade rapidly and evidence disappears. Whenever possible,
interviews will be conducted at the accident site. The site sparks a
person\'s memory, and being there also allows the supervisor to
visualize the incident.

5\. Eliminate apprehension in the witness or injured employee by
reminding the person you are seeking facts to prevent recurrence, not
placing blame. Avoid using the supervisor\'s office for conducting
interviews because a witness or injured party finds this intimidating or
distracting. Privacy is important to keep witnesses from influencing
each other.

6\. When collecting the information, try to establish a relaxed
atmosphere and be a good listener. Avoid prompting, interrupting or
leading the employee until he/she has finished a train of thought. Since
your purpose is to determine facts, phrase questions to draw out
information rather then suggesting it to the person. To reduce
misunderstanding, repeat the information as you heard it after the
employee has finished the story, to see it is what was intended.

7\. Employees who have been directly involved with the accident will be
interviewed first, followed by eyewitnesses and those who were in the
nearby area.