Broome County Incident Report Form Instructions

Overview

The Risk ICM Incident Report Form is available as an electronic Unity Form.

The [ Form Instructions ] link is located on the form and links back to this instruction page.

This form may be filled out by the primary County Employee or by another County Reporter if necessary.

Procedures

Enter the Incident Reporter

1. If blank, enter your Employee ID (abc12345) and press Tab
2. The Incident Reporter’s First Name, Last Name and Department will be auto-filled based on the Employee ID.
3. Enter a Department Division if applicable.

Enter the Incident Information

This section is used to collect general information regarding the incident.

1. If this report involves a Broome County Vehicle, select Yes to the question ‘Did This Incident Involve a Broome County Vehicle?‘, otherwise select No.
2. If police were contacted, select Yes to the question ‘Were Police Contacted?‘, otherwise select No.
   1. If police were contacted, enter the Police Agency that was contacted and the Police Report Number if known.
3. Enter the Date and Time of Incident by using the Calendar and Time tools provided after clicking in the field or typing in the following format: mm/dd/yyyy hh:mm:00 am.
4. Enter the Location of Incident in the Street, City, State, and County fields.
5. Enter a clear and concise Incident Description.

Enter the Involved Parties

This section is used for collecting information for all parties involved in the incident including County Employees (Insured), Claimants, and Witnesses.

Each added party is numbered and can be referenced in the Incident Descriptions, Damage Descriptions, Comments, as well as the Vehicle Party# field if applicable.

1. Enter the full Name of the involved party.
   Note: Involved Party #1 should be the primary County Employee involved in the incident. This may or may not be the Reporter filling out the form.
2. Select whether the involved party is an Adult or a Minor.
3. Enter the primary contact Phone Number for the involved party.
4. Select the Phone Type for the primary contact phone number noted for the involved party.
5. Enter the Address for the involved party.
6. Enter the City for the involved party.
7. Select the State for the involved party.
8. Enter the Zip Code for the involved party.
9. Select the Involvement for the involved party. The options include County Employee (Insured), Claimant, or Witness.
10. If this is an incident involving a County Vehicle, select the Role for the involved party. The options include Driver, Passenger, Pedestrian, Bicyclist, or Other.
11. If the involved party was a Driver, enter the Drivers License Number and select the State of License.
12. If the involved party is deceased as a result of the incident, select Yes for the Fatality? question, otherwise select No.
13. If the involved party sustained injuries as a result of the incident, select Yes for the Injuries? question, otherwise select No.
14. If the involved party’s personal property sustained damage as a result of the incident, select Yes for the Property Damaged? question, otherwise select No.
15. If the involved party sustained injuries as a result of the incident the Injury Information section will display.
    1. Select one or more Location of Injuries. The options include Head, Neck, Back, Torso, Arms, Hands, Legs, and Feet.
    2. If initial treatment was administered at the scene of the incident, select Yes for the Was Initial Treatment Administered? question, otherwise select either No or Unknown.
    3. If initial treatment was administered at the scene of the incident, enter What Initial Treatment Was Administered? and Who Administered Treatment?
    4. If initial treatment was administered, select Yes for the Was Hospital Treatment Administered? question, otherwise select either No or Unknown.
    5. If initial treatment was administered, enter Which Hospital?
    6. Enter a clear and concise Description of Injuries.
16. If the involved party’s personal property sustained damage as a result of the incident the Property Damage to Others Information section will display.
    1. Enter the type of Property Involved that was damaged.
    2. Enter a location for Where is the Property Now?
    3. Enter a rough Repair Estimate.
    4. Enter a clear and concise Description of Damage.
17. Enter any additional comments regarding the involved party.
18. Click the Add button on the Involved Parties section header to note additional involved parties.

Enter the Vehicle Information

This section is used for collecting information for all vehicles involved in the incident, if applicable.

1. Enter the License Plate of the involved vehicle.
   Note: Vehicle #1 should be the primary County Vehicle involved in the incident.
2. Enter the Vehicle Make of the involved vehicle.
3. Enter the Vehicle Model of the involved vehicle.
4. Enter the Year of the involved vehicle.
5. If this is a County Vehicle, enter the Fleet# if known.
6. Select the involvement of the Driver in the incident. The choices are Insured (County Employee) or Claimant.
7. Enter the related involved party Party#.
8. Enter a clear and concise Description of Damage to the Vehicle.
9. Enter a clear and concise Description of Damage to Cargo, etc.
10. Click the Add button on the Vehicle Information section header to note additional involved parties.

Create the Automobile Accident Diagram

This section is used for providing a rough diagram of all vehicles, pedestrians, bicycles, etc. involved in the incident, if applicable, to approximate their location in relation to each other. This, in addition to the description, is to initiate the investigation.

Indicate on this diagram what happened. Sketch the scene of your accident.

1. Draw a box for each vehicle using the pencil tool.
2. Denote each vehicle by typing the number from the Vehicle Information in each box using the ‘abc‘ tool.
   Note: The Broome County vehicle should be #1.
3. Show direction of travel by drawing an arrow using the pencil tool.
4. Show pedestrians by typing a ‘P‘ using the ‘abc‘ tool.
5. Show bicycles by typing a ‘B‘ using the ‘abc‘ tool.

Note: You can use the Clear and Undo buttons as well as the Eraser tool to adjust the diagram if needed.

Attach Photos and Related Documentation

Upload any photos taken at the time of the incident including driver’s license, insurance cards, damage, etc.

1. Click the Attach Photos or Reports button
2. Browse to the location of the document
3. Select the document
4. Click the Open button to attach the document
5. Repeat steps 1 – 4 for each document
6. If an incorrect document has been attached, click the Remove link to the right of the filename

Sign and Submit the Form

Once all relevant information has been provided on the form it can be signed and submitted.

Checking this box and typing your name constitutes a signature and agreement to this declaration.

1. Check the box to acknowledge the statement ‘By signing this document I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief‘.
2. Type your name as it appears to sign the document
3. Click the Submit button to initiate the Incident Reporting Process