Date of Incident, Injury, or Illness
Full Name of Employee or Individual Involved
Employee's (or Individual's) Full Address
Date of Birth
Male or Female
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?
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
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
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?
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?
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?
Supervisor Full Name (or person completing this form)
When were 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