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Incident & Injury Report

Today's Date

Time of Incident, Injury, or Illness

Information about the employee or individual involved

Phone Number of Employee or Individual Involved (cell phone preferred)

Department

Title of Employee

Employee's direct supervisor:

How long has the employee been in this job or position?

Male or Female

Male

Female

Time employee's shift started

Information about the Incident

Did this incident take place on a roadway?

Yes

Parking Lot

Describe the specific location of the incident

What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

What happened? Tell us how the injury, illness, incident or near miss occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."

Did the employee sustain an injury?

Yes

Was City property damaged? Please explain in detail.

What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn, left hand", "carpel tunnel syndrome."

What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this section does not apply to the incident, leave it blank.

Nature of injury: (select the most serious one)

Describe the existing injury

Did the injury require medical treatment?

Yes

Name of doctor, clinic, or medical facility visited:

Was the employee treated in an Emergency Room or Hospital?

Yes

Was the employee hospitalized overnight or admitted as an inpatient?

Yes

What steps are being taken to prevent a similar incident?

When did the incident occur?

Entering or leaving work

During normal work activities

During meal period or break

During unusual work activity

Working overtime

While traveling for work

Describe what other safety equipment was being used:

List any witnesses and their contact information:

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

Yes

Was This Incident Preventable?

Yes

If This Incident Was Unavoidable, Please Explain

Additional Personnel

Was a 2nd employee or person injured?

Yes

2nd person's Phone Number (cell phone preferred)

2nd Person's Department

2nd Person's Title

How long has the 2nd employee been in this job or position?

2nd Employee's Direct Supervisor

Sex of the 2nd Employee

Male

Female

Time 2nd employee's shift started

Motor Vehicle and/or Equipment Incident

Did the incident involve City equipment NOT INCLUDING motor vehicles?

Yes

Equipment Year, Make, & Model

List All Safety Equipment & PPE Being Used

Equipment City ID #

Was The Incident Caused By Mechanical Failure?

Did the incident involve a motor vehicle(s)?

Yes

Did police investigate this incident?

Yes

List the Incident Report # and send the police report to Risk Management in HR

Vehicle Incident Type

Collision

Non-collision

Vehicle #1

Year, Make, & Model of Vehicle #1

License Plate # for Vehicle #1

Vehicle City ID (if it is a City vehicle)

List any passengers that were in Vehicle #1

Was anyone injured in vehicle #1?

Yes

Was everyone in Vehicle #1 wearing a seat belt?

Yes

Unknown

List passengers that were not wearing a seat belt:

Was there a 2nd vehicle involved in this incident?

Yes

Vehicle #2

Is the driver the owner of Vehicle #2?

Yes

Year, Make, & Model of Vehicle #2

License Plate# for Vehicle #2

Vehicle #2 City ID (if it is a City Vehicle)

List any passengers that were in Vehicle #2

Was anyone injured in Vehicle #2?

Yes

Was everyone in Vehicle #2 wearing a seat belt?

Yes

List any passengers that were not wearing a seat belt in Vehicle #2:

Was there a 3rd vehicle involved in the incident?

Yes

Vehicle #3

Is the driver the owner of Vehicle #3?

Yes

Year, Make, & Model of Vehicle #3

License Plate # of Vehicle #3

Vehicle #3 City ID# (if it is a City vehicle)

List any passengers in Vehicle #3

Was anyone injured in Vehicle #3?

Yes

Was everyone in Vehicle #3 wearing a seat belt?

Yes

List any passengers not wearing a seat belt:

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

Yes

Describe other damaged City property

Information on supervisor or person completing this form

Title of person completing form

Phone Number (cell phone preferred)

Time you were notified

How were you notified?

Phone

Text

In Person

Radio

Another Co-Worker

Other

Department filling out report

Select the appropriate division within the Fire Department

A Shift

B Shift

C Shift

Fire Prevention

Training Division

Maintenance

Administration

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

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Incident & Injury Report

Today's Date

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