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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.
NOTE: A Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure form MUST be completed with an Employee is injured.
NOTE: A Fleet Service Request MUST be completed when a City Fleet Vehicle/Equipment is damaged.
Complete Service Request before proceeding further. Number required below on this form.
Any and all property damage must be listed to include an Employee's private property if any.
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.
Please check all that apply.
*If a witness was involved, please complete a Witness Statement Form.
Must be filled out by the Supervisor
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.
This field is not part of the form submission.
* indicates a required field