The [DA 2041] Accident Report (Louisiana State Driver Safety Program) form must be completed within 24 hours of the automobile accident in a State owned and/or rented/leased vehicle being used on state business and submitted to the EHS Office via email at csmith062@nsula.edu or Room 122 of the Facility Services Building.
Please do not fax the form, as it must be legible to ORM/FARA.
This report will then be sent to ORM/FARA within 48 hours of the accident. Even if all blanks cannot be filled in, please complete what you can and submit the report. Upon receipt of the form, the EHS Office will e-mail the completed form to ORM-DA2041@la.gov .
Please either print or type this form. This is a box-by-box instruction sheet for completing the form.
GENERAL INFORMATION
1. Agency Name: Northwestern State University
2. Contact Person for the Agency: Chelsea Eddington, EHS Officer
3. Phone number of the contact person: (318) 357-4424
4. ORM Location Code for Agency: 5160
5. State Vehicle Driver’s Name: This is the person driving the vehicle at the time of the accident; this must be the driver’s legal name.
6. Personnel Number: Enter the Driver’s Campus ID Number
7. Date of Accident: enter the date the accident occurred
8. Time of accident: Enter time of accident, please indicate AM or PM.
9. Exact Location of Accident: Enter the exact street names, intersection, milepost numbers, basically anything that will give the exact location. If you do not know, please ask the police officer that responds to the accident scene.
10. Describe how accident happened: Please provide as many details as possible as to how the accident happened. Include other vehicles, traffic lights, traffic signs or anything that may have played a role in the cause of the accident.
11.Seatbelt in Use: Indicate yes or no
STATE VEHICLE INFORMATION
12. State vehicle Driver’s Address: please give complete address to include city, state and zip code.
13. State Vehicle Drivers Home Phone: This can be home or cell number, include area code.
14. State vehicle driver’s Work Phone: Work phone number, include area code.
15. State vehicle driver’s license number: Include state and driver’s license number.
16. Age of State Driver
17. Sex of State Driver: Please indicate male or female.
18. Vehicle Owner’s name and address:
If NSU owned vehicle:
Northwestern State University
735 University Parkway/P.O. Box 5303
Natchitoches, LA 71457
If rented/leased vehicle, please check in vehicle for ownership paperwork.
19. Year of vehicle: can be located on registration
20. Make of vehicle: can be located on the registration
21. Model of vehicle: can be located on the registration
22. Body type: (4 door, 2 door, pickup, van)
23. Vehicle license number/Equipment Number/VIN:
License plate number: from the license plate on the vehicle
Equipment Number: This is the NSU car number.
VIN: This is a 17 digit/letter combination that is located on the registration.
24A. Where can the vehicle be seen? If drivable—indicate Northwestern State University. If the vehicle was towed, please indicate what wrecker service towed the vehicle, with a phone number.
24B. Describe damages: Indicate all areas of the vehicle that are damaged.
OTHER VEHICLE INFORMATION
This section must be completed for every “other” vehicle involved in the accident.
25. Other vehicle Driver’s name: You need to obtain the drivers name.
26. No longer required.
27. Other vehicle Driver’s license number: This would be helpful, state and driver’s license number.
28. Other vehicle driver’s age
29. Other vehicle driver’s sex: Indicate male or female
30. Other driver’s street address: Get a complete address including city, state and zip code.
31. Other vehicle Drivers Home Phone Number: This can be home or cell number.
32. Other vehicle drivers work phone: Work phone number or other phone number.
33. Vehicle owners name and address: If different from the driver. Be sure to get the city, state and zip code.
34. Year of vehicle: can be located on the registration
35. Make of vehicle: can be located on the registration
36. Model of vehicle: can be located on the registration
37. Body Type of Vehicle: (4 door, 2 door, pickup, van)
38. License number/Equipment number/VIN of other vehicle: can be obtained from registration.
39. Where can the vehicle be seen? Enter drivers address or Towing Company name and phone number.
40. Other Vehicle Insurance Company: full name of the insurance card for the other vehicle
41. Policy Number: other vehicle’s insurance policy number
42. Describe damage to vehicle: Indicate all areas of the vehicle that are damaged.
43. Estimate amount: not required for the 48 hour submittal.
INJURED
44. Name and address of Injured Person: name and complete address of any injured persons.
45. Phone number: any phone number where injured person can be reached.
46. PED: Check this box if the injured person was a pedestrian involved in the accident.
47. INS VEH: If the driver and/or passenger were injured in the State Insured vehicle, then place a check in the box.
48. OTHER VEH: If the driver and/or passenger were injured in the other vehicle, then place a check in the box.
49. Police Investigation: Indicate Yes or No—this should be yes, because all accidents involving state vehicles or leased vehicles for state business should be reported to the local police.
Type Report: Indicate what type agency worked the accident.
Report Number: Indicate report number here if it is known.
WITNESSES OR PASSENGERS
50. Name and Address: Indicate the name and full address of any passengers and/or witnesses.
51. Witness or Passenger: Please check the appropriate box to verify if the witness is an independent individual and not a passenger in either vehicle. If the witness is a passenger
in the State or other vehicle, then check the box in item 53 to indicate which vehicle the passenger occupied.
52. Phone number for the witness/passenger.
53. PED: Check this box if the witness was a pedestrian.
INS VEH: If the passenger was in the State Insured vehicle, then place a check in the box.
OTHER VEH: If the passenger was in the other vehicle, then place a check in the box.
54. Signature of the State Driver: The driver of the state vehicle involved in the accident must sign.
55. Name of the state driver’s immediate supervisor and a phone number with area code.
