Employee Incident Form

Employee Information* is required

*First Name:

*Last Name:

*Home Address:

*City:

*State:

*Zip:

*Home Phone:

*Date of Hire:

*Hourly Wage:

*Time Employee began work:

*Employment Status:

Full Time Part Time

*Supervisor:

*Department:

Incident Information

*Date of Incident:

*Time of Incident:

*Please describe the incident, giving full details include: Where? What? When? How? Why?

Witnesses:

Witness Phone:

If delayed reporting, give reason:

Was Safety Equipment Used? (PPE, Gloves, Mask, Eyewear, ETC.):

Region of Body:

Part of Body:

Did you receive First Aid Treatment onsite?

Yes No

By whom? When?

Did you go to Work-Med?

Yes No

If no, what clinic or Hospital did you go to?

Clinc/Hospital Office Phone:

How many days of work did you miss due to this injury?

Were you placed on restricted duty?

Yes No

If so, what restrictions?

Was inmate/suspect involved?

Yes No

If so, name?

*Location/Address of Incident:

*City:

*State:

*Zip:

Additional Information:

Employee Signature

*Employee Signature:

*Date Completed:

(Optional) Email a copy of the report to:

Employee Email:

Supervisor Email:

Other Email:

Employee Report of Incident / Injury

Employee Information* is required

Incident Information

Employee Signature