GSA_3620_non-GSA_employee_personal_injury.pdf

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Operation & Maintenance and Elevator Services
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GS-11-P-16-YE-D-7001
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GSA 3620 NON GSA Employee Personal Injury

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REPORT OF GSA PROPERTY DAMAGE OR

NON-GSA EMPLOYEE PERSONAL INJURY

This form is not to be used for reporting GSA motor vehicle accidents or GSA employee occupational injuries/illnesses. Use Standard Form 91 or 91A or CA-1 or CA-2 respectively. See reverse for complete instructions.

4. PERSON'S NAME AND HOME ADDRESS

REPORT CONTROL NUMBER

1. REGION 2. DATE OF ACCIDENT

3. ACCIDENT REPORT NUMBER

5. REASON FOR REPORT

6. PERSON'S TELEPHONE NUMBER 7. TIME OF ACCIDENT

AM PM

8. EXACT LOCATION OF ACCIDENT 9. NAME AND ADDRESS OF GSA FACILITY

10. MEDICAL EXPECTATION

12. OWNER OF EQUIPMENT/VEHICLE INVOLVED

A. NAME

C. TELEPHONE NUMBER

B. ADDRESS

13. DETAILED DESCRIPTION OF ACCIDENT

14. CORRECTIVE ACTION

A. DESCRIPTION

C. ACTION DATE

15. NAME AND TITLE OF SUPERVISOR SIGNATURE OF SUPERVISOR 17. TELEPHONE NUMBER

18. DATE

19. COMMENTS

A. REVIEWING OFFICIAL B. S&EM CLEARANCE OFFICIAL

20. NAME AND TITLE OF REVIEWING OFFICIAL

23. NAME AND TITLE OF S&EM CLEARANCE OFFICIAL

21. SIGNATURE OF REVIEWING OFFICIAL

24. SIGNATURE OF CLEARANCE OFFICIAL

22. DATE

25. DATE

11. DESCRIBE EQUIPMENT INVOLVED

B. RESPONSIBLE PERSON

INSTRUCTIONS FOR COMPLETING GSA FORM 3620

(Print or type all entries except where signatures are required)

Item No. Instructions

1 List region reporting the accident.

2 Show date of the accident.

3 Leave blank. The Regional S&EM Office enters the report number.

4 Identify the person most responsible or involved in the accident. If more than one, use separate blank paper.

5 State precisely why this report is being completed (e.g.; Non-Federal personal injury, Federal property damage, Non-Federal property damage).

6 Give the telephone number of the person most responsible or involved in the accident If more than one person, make sure this number is included with Item 4.

7 --8 Self-explanatory.

9 Identify the name and address of the GSA facility involved in the accident

10 If a personal injury is involved, what is the exact nature of the injury and what is the actual or expected result (e.g. death, amputation of the left leg, fractured right arm, strained back). Note if hospitalized and where.

11 --13 Self-explanatory. Use additional paper if necessary.

14A Specifically, what needs doing or what was done to correct the cause of the accident

14B Identify individual responsible for corrective action.

14C State when corrective action was or will be complete.

15 --18 The person preparing the report is the supervisor in charge of the area or equipment involved.

19A The reviewing official should use this space for comments.

19B The S&EM Branch should use this space for comments.

20 --22 The reviewing official is the facility manager or equivalent

23 --25 The Regional Safety and Environmental Management Branch Chief is considered the clearance official.

page)

REPORT OF GSA PROPERTY DAMAGE OR

NON-GSA EMPLOYEE PERSONAL INJURY

This form is not to be used for reporting GSA motor vehicle accidents or GSA employee occupational injuries/illnesses. Use Standard Form 91 or 91A or CA-1 or CA-2 respectively. See reverse for complete instructions.

4. PERSON'S NAME AND HOME ADDRESS

REPORT CONTROL NUMBER

1. REGION

2. DATE OF ACCIDENT

3. ACCIDENT REPORT NUMBER

5. REASON FOR REPORT

6. PERSON'S TELEPHONE NUMBER

7. TIME OF ACCIDENT

AM

PM

8. EXACT LOCATION OF ACCIDENT

9. NAME AND ADDRESS OF GSA FACILITY

10. MEDICAL EXPECTATION

12. OWNER OF EQUIPMENT/VEHICLE INVOLVED

A. NAME

C. TELEPHONE NUMBER

B. ADDRESS

13. DETAILED DESCRIPTION OF ACCIDENT

14. CORRECTIVE ACTION

A. DESCRIPTION

C. ACTION DATE

15. NAME AND TITLE OF SUPERVISOR

SIGNATURE OF SUPERVISOR

17. TELEPHONE NUMBER

18. DATE

19. COMMENTS

A. REVIEWING OFFICIAL

B. S&EM CLEARANCE OFFICIAL

20. NAME AND TITLE OF REVIEWING OFFICIAL

23. NAME AND TITLE OF S&EM CLEARANCE OFFICIAL

21. SIGNATURE OF REVIEWING OFFICIAL

24. SIGNATURE OF CLEARANCE OFFICIAL

22. DATE

25. DATE

11. DESCRIBE EQUIPMENT INVOLVED

B. RESPONSIBLE PERSON

INSTRUCTIONS FOR COMPLETING GSA FORM 3620

(Print or type all entries except where signatures are required)

Item No. Instructions

1 List region reporting the accident.

2 Show date of the accident.

3 Leave blank. The Regional S&EM Office enters the report number.

4 Identify the person most responsible or involved in the accident. If more than one, use separate blank paper.

5 State precisely why this report is being completed (e.g.; Non-Federal personal injury, Federal property damage, Non-Federal property damage).

6 Give the telephone number of the person most responsible or involved in the accident If more than one person, make sure this number is included with Item 4.

7 --8 Self-explanatory.

9 Identify the name and address of the GSA facility involved in the accident

10 If a personal injury is involved, what is the exact nature of the injury and what is the actual or expected result (e.g. death, amputation of the left leg, fractured right arm, strained back). Note if hospitalized and where.

11 --13 Self-explanatory. Use additional paper if necessary.

14A Specifically, what needs doing or what was done to correct the cause of the accident

14B Identify individual responsible for corrective action.

14C State when corrective action was or will be complete.

15 --18 The person preparing the report is the supervisor in charge of the area or equipment involved.

19A The reviewing official should use this space for comments.

19B The S&EM Branch should use this space for comments.

20 --22 The reviewing official is the facility manager or equivalent

23 --25 The Regional Safety and Environmental Management Branch Chief is considered the clearance official.

12. OWNER OF EQUIPMENT/VEHICLE INVOLVED:
4. PERSON'S NAME AND HOME ADDRESS:
8. EXACT LOCATION OF ACCIDENT:
10. MEDICAL EXPECTATION:
9. NAME AND ADDRESS OF GSA FACILITY:
5. REASON FOR REPORT:
REPORT CONTROL NUMBER:
1. REGION:
3. ACCIDENT REPORT NUMBER:
6. PERSON'S TELEPHONE NUMBER:
7. TIME OF ACCIDENT. AM.:
7. TIME OF ACCIDENT. PM.:
A. NAME:
C. TELEPHONE NUMBER:
B. ADDRESS:
13. DETAILED DESCRIPTION OF ACCIDENT:
14. CORRECTIVE ACTION:
A. DESCRIPTION:
B. RESPONSIBLE PERSON:
17. TELEPHONE NUMBER:
15. NAME AND TITLE OF SUPERVISOR:
19. COMMENTS:
A. REVIEWING OFFICIAL:
B. S&EM CLEARANCE OFFICIAL:
20. NAME AND TITLE OF REVIEWING OFFICIAL:
23. NAME AND TITLE OF S&EM CLEARANCE OFFICIAL:
24. SIGNATURE OF CLEARANCE OFFICIAL:
21. SIGNATURE OF REVIEWING OFFICIAL:
24. SIGNATURE OF CLEARANCE OFFICIAL:
21. SIGNATURE OF REVIEWING OFFICIAL:
25. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
22. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
18. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
C. ACTION DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
2. DATE OF ACCIDENT. Enter 2 digit month, 2 digit day and 4 digit year.:
11. DESCRIBE EQUIPMENT INVOLVED:
SIGNATURE OF SUPERVISOR:
SIGNATURE OF SUPERVISOR:

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