Commissioner Darin R. Seeley
MENU
Home
Services for State Government Agencies
Services for South Dakota Citizens
Office Remodel Request Form
BOA Resource Guide
Central Services
Central Mail
Central Duplicating
Property Management
Records Management
Procurement Management
Space Management
Buildings & Grounds
Federal Surplus Property
State Engineer
Office of the State Engineer
Energy Management
Risk Management
Fleet & Travel
Obligation Recovery Center
Hearing Examiners
Office of Risk Management
Craig Ambach, Director
Risk Management Contact Information:
1429 East Sioux Avenue
Pierre, SD 57501
ph 605-773-5879
fax 605-773-5880
SECONDARY MENU
News
Services
Forms
Risk Contacts
Risk Manual
FAQ
Frequently Found Issues
Power Point Presentations
South Dakota Safety Council
Incident, Accident or Unsafe Condition Report
< Print Form to Complete by Hand
Accident Information
Department:
* Required
REQUIRED
Agency/Division:
* Required
REQUIRED
Date of Accident:
* Required
REQUIRED
Time of Accident:
am
pm
* Required
REQUIRED
Type:
Accident
Incident
Unsafe Condition
Location of Accident, Incident, or Unsafe Condition:
* Required
REQUIRED
Employee Completing Report
Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Title:
* Required
REQUIRED
Employment Status:
Temporary
Permanent
* Required
REQUIRED
Work Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Person Involved in the Accident or Incident
Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Address:
* Required
REQUIRED
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Occupation:
* Required
REQUIRED
Business Address:
* Required
REQUIRED
Business Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
What was the person involved doing at the time of the accident or incident:
Injury
What was the nature and extent of the injury?
Was first-aid administered?
Yes
No
If yes, by whom?
Describe the type of first-aid treatment given:
Was medical treatment administered?
Yes
No
If yes, by whom?
Name and address of medical facility:
Did accident result in fatality?
Yes
No
* Required
REQUIRED
Property Damage
Owner:
(include address and phone)
* Required
REQUIRED
Damage Description:
(include estimated repair costs)
* Required
REQUIRED
Witnesses
Name:
(include address and phone)
Name:
(include address and phone)
Accident Description
Describe in detail:
* Required
REQUIRED
Include Pictures Here:
Legal
Was Law Enforcement Contacted?
Yes
No
* Required
REQUIRED
Name of Law Enforcement Agency:
Signature
Signature:
(type name in signature box)
* Required
REQUIRED
Date:
* Required
REQUIRED