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City of Clarksville

tamara.welker@cityofclarksville.com

One Public Square, Suite 201 , Clarksville, TN, 37040, US

Incident & Injury Report

Today's Date

Date Picker

Date of Incident, Injury, or Illness

Information about the employee or individual involved

Full Name of Employee or Individual Involved

Employee's (or Individual's) Full Address

Date of Birth

Date Hired

Male or Female

Information about the Incident

Address of incident or closest address

Did this incident take place on a roadway?

Did the employee sustain an injury?

Select the body part that was affected:

Did the injury require medical treatment?

Was the employee treated in an Emergency Room or Hospital?

Was the employee hospitalized overnight or admitted as an inpatient?

When did the incident occur?

Safety equipment being used at the time of the incident:

Have the employee(s) been trained on the task that was being performed?

Was This Incident Preventable?

Additional Personnel

Was a 2nd employee or person injured?

2nd Person's Full Name

2nd Person's Full Address

2nd Person's Date of Birth

2nd Person's Date Hired

Sex of the 2nd Employee

Motor Vehicle and/or Equipment Incident

Did the incident involve City equipment NOT INCLUDING motor vehicles?

Please check all types of equipment involved in this incident

Equipment Operator Full Name

Did the incident involve a motor vehicle(s)?

Select All Types of Equipment That Were Involved

Did police investigate this incident?

Vehicle Incident Type

Select all that the collision involved

Vehicle #1

Driver of Vehicle #1 Full Name

Was anyone injured in vehicle #1?

Was everyone in Vehicle #1 wearing a seat belt?

Was there a 2nd vehicle involved in this incident?

Vehicle #2

Driver of Vehicle #2 Full Name

Is the driver the owner of Vehicle #2?

Full Name of Vehicle #2 Owner

Was anyone injured in Vehicle #2?

Was everyone in Vehicle #2 wearing a seat belt?

Was there a 3rd vehicle involved in the incident?

Vehicle #3

Driver of Vehicle #3 Full Name

Is the driver the owner of Vehicle #3?

Full Name of the owner of Vehicle #3

Was anyone injured in Vehicle #3?

Was everyone in Vehicle #3 wearing a seat belt?

Was any other City property damaged that is not already listed?

Information on supervisor or person completing this form

Supervisor Full Name (or person completing this form)

When where you notified about the incident?

How were you notified?

Select the appropriate division within the Fire Department

Upload File(s) or Picture(s) that will help complete the report