Pod Form 265 E PDF Details

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QuestionAnswer
Form NamePod Form 265 E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespod form 265 e, payable on death template, payable on death beneficiary form, payable on death form

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U.S. ARMY CORPS OF ENGINEERS, PACIFIC OCEAN DIVISION HEADQUARTERS

IMMEDIATE REPORT OF ACCIDENT

For use of this form, see EM 385-1-1, the proponent agency is CEPOD-SO

SOHO USE ONLY

DATE RECORDED

TIME RECORDED

TO (COE OFFICE):

FROM:

1. NAME OF PERSON REPORTING ACCIDENT

 

 

 

 

 

 

1a. PHONE NO.

 

 

2. ACCIDENT INFORMATION (CHECK ALL THAT APPLY):

 

 

 

 

 

 

 

 

 

 

INJURY

 

INITIAL REPORT

 

CONTRACTOR

 

PROPERTY DAMAGE

 

 

 

 

 

 

 

 

 

ILLNESS

 

FOLLOW UP REPORT*

 

GOVERNMENT

 

OTHER (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FATALITY

 

FINAL REPORT

 

PUBLIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*A follow up report is due within 24 hours of any changes or additional information related to the accident (e.g., workers duty status)

3. CONTRACTOR/SUBCONTRACTOR

3a. CONTRACT NO.

 

 

 

4. LOCATION OF ACCIDENT (be specific, include project name and number)

4a. DATE OF ACCIDENT

4b. TIME OF ACCIDENT

 

 

 

5. NAME OF PERSON INVOLVED/INJURED (Last name, First name)

5a. AGE

5b. OCCUPATION

6.What was the activity before the accident occurred? Describe the activity, as well as the tools, equipment, or materials the employee was using (e.g., excavating with a backhoe, electrical equipment installation, demolition of facility, erecting structural steel):

7.What Happened? Tell how the injury, illness, or property damage occurred (e.g., struck by, contacted by, cut by, strained by, fell from same or different level, stung by):

8.What was the injury, illness or property damage (e.g., contusion, bruise, muscle strain, fracture, respiratory, allergic reaction, skin disease, poisoning, collapsed crane boom, engine fire, damaged utilities)?

9.Is the injury, illness, or property damage recordable as defined in OSHA 29 CFR Part 1904 or ER 385-1-99? If yes, an ENG Form 3394 must be submitted within 10 days. Note: An injury or illness is recordable if it results in death, days away from work, transfer to another job, restricted work, medical treatment

beyond first aid, loss of consciousness or other significant illness. Property damage of $2000.00 or more is recordable.

Yes

No

10.What medical treatment was required for the injury or illness (e.g., first aid, sutures, prescription medication, x-rays, cast)?

11.If medical treatment was given away from the work site, where was it given?

12.

Was employee hospitalized overnight as an in-patient?

13. Estimated days away from

13a. Estimated Job Transfer or

13b. Estimated days

 

Yes

No

work:

Restricted Days:

hospitalized:

 

 

 

 

 

 

 

 

 

 

 

15.

Did accident result in property damage?

16. If yes, estimated property damage (if property damage is $2000 or greater ENG Form 3394

 

Yes

No

must be completed and submitted)

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

**Accident Board of Investigation Required?

17a. If yes, was immediate notification to the designated authorities made? District Safety Officer

 

 

 

 

Yes

No

and Commander must be notified of all serious cases.

Yes

No

 

 

 

 

 

 

 

**A board of investigation is required if the the accident results in: A. a fatality, B. three or more people admitted to the hospital, C. permanent total or partial disability, or D. property damage of $500,000 and greater.

18. NAME AND TITLE OF INDIVIDUAL WHO WILL INVESTIGATE THIS ACCIDENT

NAME AND TITLE OF PERSON REPORTING

PHONE:

SIGNATURE

DATE

POD FORM 265-E, OCT 2011

THIS FORM REPLACES POD 265-R DATED 14 JUN 2006.

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CONTINUATION PAGE

POD FORM 265-E, OCT 2011

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