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Supervisor's Report of Incident Form

  1. Supervisor's Report of Incident Form

    An incident form should be completed for ALL incidents, accidents and emergencies. This form must be completed immediately after the incident or accident occurs. Please provide as much detail as possible. Attach additional pages if necessary. A separate incident form should be completed for each injured individual. The Supervisor's Incident Form is a Privileged and Confidential report to City Attorney and Risk Management.

  2. Check as Appropriate*



    NOTE:  A Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure form MUST be completed with an Employee is injured.

  3. City Fleet Vehicle/Equipment Damaged?*


    NOTE:  A Fleet Service Request MUST be completed when a City Fleet Vehicle/Equipment is damaged.  Ops Staff: Contact Apparatus Specialist to get fleet service order number.

  4. Private Property Damage?*


    Any and all property damage must be listed to include an Employee's private property if any.

  5. PART A: Contact Information of Person Involved
  6. Person Involved is a:*
  7. PART B: Parent/Guardian Contact information (If Minor)
  8. PART C: Details of Incident
  9. Staff Member in charge or on duty:
  10. PART D: Injury

    NOTE: This part will be hidden if there is no injury associated with the incident. Checking "Member of the Public Injury" OR "Employee Injury" will reveal this section.

  11. Indicate type of care
  12. Injured person was
  13. Indicate which part(s) of the body was injured


    Please check all that apply.

  14. PART E: Witness Information

    If employee; only name, email, phone number needed.

  15. Witness #1
  16. Witness is a:
  17. Witness #2

    If employee; only name, email, phone number needed.


  18. Witness is a:
  19. Witness #3

    If employee; only name, email, phone number needed.


  20. Witness is a:
  21. PART F: Other Information
  22. PART G: Preparation and Review
  23. Report prepared by:
  24. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  25. Leave This Blank:

  26. This field is not part of the form submission.