Employee Report of Incident / Injury

If you have any questions, please call 801-399-8624, Fax 801-399-8307. This form must be completed and submitted to HR before the end of the work-shift if possible.

For property damage only, contact Kim Lee, 801-399-8604 for a separate report. Looking for the Supervisor Report of Incident form

Employee Information* is required

Incident Information

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

Additional Information:

Employee Signature

(Optional) Email a copy of the report to: