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2. 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.

6. Check as Appropriate*

   1. Member of the Public Injury
   2. Employee Injury

   1. City Property Damage
   2. Private Property Damage

   
   

   
   

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

8. Click for Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure
   Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form
10. City Fleet Vehicle/Equipment Damaged?*

    1. Yes

    1. No

    
    

    NOTE:  A Fleet Service Request MUST be completed when a City Fleet Vehicle/Equipment is damaged.

12. Click for Fleet Service Request
    Fleet Service Request Link

    
    

    Complete Service Request before proceeding further. Number required below on this form.

14. Fleet Service Request Number
16. Private Property Damage?*

    1. Yes

    1. No

    
    

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

20. PART A: Contact Information of Person Involved
22. Last Name*
23. First Name*
25. Date of Birth*
    Date of Birth
26. Driver's License # or ID #*
28. Email Address*
30. Address*
32. City*
33. State*
34. Zip Code*
36. Phone #*
37. Alternate Phone #
39. Person Involved is a:*

    1. Employee

    1. Volunteer

    1. Member of the Public

    1. Contractor
43. PART B: Parent/Guardian Contact information (If Minor)
45. Was a Parent/Guardian/Relative Contacted?
    -- Select One --YesNo
46. Relation:
48. First Name
49. Last Name
50. Driver's License # or ID #
52. Email Address
54. Address
56. City
57. State
58. Zip Code
60. Phone #
61. Alternate Phone #
65. PART C: Details of Incident
67. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
69. Address*
71. City*
72. State*
73. Zip Code*
75. Staff Member in charge or on duty:
77. First Name*
78. Last Name*
79. Department*
    -- Select One --Community DevelopmentCity AttorneyCity ClerkCity ManagerFinanceFire DepartmentHuman ResourcesParks and RecreationPolice DepartmentPublic WorksUtilities
81. Employee ID*
82. Employee Email Address*
84. Employee(s) Involved*
86. Was a City Vehicle Involved?*
    -- Select One --YesNo
87. City Vehicle Number Type
88. City Vehicle License #
89. City Vehicle Model
91. Was a Private Vehicle Involved?*
    -- Select One --YesNo
92. Private Vehicle Year/Make
93. Private Vehicle License #
94. Private Vehicle Model
96. Private Insurance Carrier
97. Private Driver's License #
99. Please indicate in words where the incident occurred (specific location) and the condition of the incident area.*

    Individuals name

101. Please list all damages to vehicle/equipment/City Property*
103. Upload Photo of Damage #1 (Required)*
104. Upload Photo of Damage #2 (Optional)
105. Upload Photo of Damage #3 (Optional)
107. Upload Photo of Damage #4 (Optional)
108. Upload Photo of Damage #5 (Optional)
109. Upload Photo of Damage #6 (Optional)
111. Attached photos were taken by:*
113. Provide a detailed description of the incident. Record everything leading up to the incident and the actual incident. If the person involved was injured DO NOT indicate the care provided in this section.*
115. Statement by person involved*
117. Was "911 Called?*
     -- Select One --YesNo
118. Person who called "911"
120. Was the Police Dept. Notified?
     -- Select One --YesNo
121. Was the Fire Dept. Notified?
     -- Select One --YesNo
122. Case #
124. Was a Supervisor Called?*
     -- Select One --YesNo
125. Supervisor Name
126. Date and Time Supervisor was called
     Date and Time Supervisor was called

     Date and Time Supervisor was called
130. 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.

132. Indicate type of care

     1. CPR
     2. AED

     1. First-Aid
     2. No Care Provided

     1. Refused care
134. Primary responder
135. Primary care provider
136. Other care providers
138. Injured Person First Name
139. Last name
141. Address
143. City
144. State
145. Zip Code
147. Injured Person #2 First Name
148. Last Name
150. Address
152. City
153. State
154. Zip Code
156. Injured person was

     1. Transported to hospital
     2. Went to doctor's office
     3. Released to parent/guardian
     4. Released to family member (if not a minor)

     1. Advised to seek further medical attention
     2. Refused treatment
     3. Went home
     4. Remained in area
158. Indicate which part(s) of the body was injured

     1. Left Shoulder
     2. Left Upper Arm
     3. Left Lower Arm
     4. Left Elbow
     5. Left Wrist
     6. Left Hand
     7. Right Shoulder
     8. Right Upper Arm
     9. Right Lower Arm

     1. Right Elbow
     2. Right Wrist
     3. Right Hand
     4. Left Ankle
     5. Left Lower Leg
     6. Left Foot
     7. Left Hip
     8. Left Thigh
     9. Right Ankle

     1. Right Lower Leg
     2. Right Foot
     3. Right Hip
     4. Right Thigh
     5. Head
     6. Chest
     7. Neck
     8. Nose
     9. Groin

     1. Buttocks
     2. Finger
     3. Toe
     4. Left Eye
     5. Right Eye
     6. Abdomen
     7. Back
     8. Face

     
     

     Please check all that apply.

160. Provide specific details of the care provided
164. PART E: Witness Information
166. Witness #1
168. First Name
169. Last Name
170. Phone #
172. Email Address
174. Address
176. City
177. State
178. Zip
180. Witness is a:

     1. Employee

     1. Volunteer

     1. Member of the Public

     1. Contractor
182. Was a signed witness statement/form completed?
     -- Select One --YesNo
184. Witness Statement Form
     Witness Statement Form

     *If a witness was involved, please complete a Witness Statement Form.

186. Witness #2
188. First Name
189. Last Name
190. Phone #
192. Email Address
194. Address
196. City
197. State
198. Zip
200. Witness is a:

     1. Employee

     1. Volunteer

     1. Member of the Public

     1. Contractor
202. Was a signed witness statement/form completed?
     -- Select One --YesNo
204. Witness Statement Form
     Witness Statement Form

     *If a witness was involved, please complete a Witness Statement Form.

206. Witness #3
208. First Name
209. Last Name
210. Phone #
212. Email Address
214. Address
216. City
217. State
218. Zip
220. Witness is a:

     1. Employee

     1. Volunteer

     1. Member of the Public

     1. Contractor
222. Was a signed witness statement/form completed?
     -- Select One --YesNo
224. Witness Statement Form
     Witness Statement Form

     *If a witness was involved, please complete a Witness Statement Form.

     
     

228. PART F: Other Information
230. If needed, please use the space provided to include any additional information
232. Was a service request created?*
     -- Select One --YesNo
234. Service Request/Lucity Work Order Number
236. What Department actions were taken to prevent future damage/accident?*

     Must be filled out by the Supervisor

240. PART G: Preparation and Review
242. Supervisor Name:
244. First Name
245. Last Name
246. Job Title
248. Department Head Name:
250. First Name
251. Last Name
252. Job Title
254. Director Name:
256. First Name
257. Last Name
258. Job Title
260. Report prepared by:
262. First Name
263. Last Name
264. Job title
266. 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.

     1. I agree.
268. Electronic Signature (Person who Prepared Report)*
269. Date and Time
     Date and Time

     Date and Time
Leave This Blank:


271. 1. Receive an email copy of this form.
272. Email address

     This field is not part of the form submission.

273. Submit

* indicates a required field