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Supervisor's Report of Work-Related Injury, Illness, Exposure or Near Miss

  1. Routed to Risk Management & Human Resources, CC'd to Supervisor
    CC'd Recipient: This Form is For Awareness Only, No Further Action Required.
  2. This form is to be completed by the Supervisor for each employee who reports a work-related injury, illness, or exposure. The supervisor must submit this form on the day of incident.
    This form is to be filled out by City of Napa Employees
  3. Is This an Update of a Previously Reported Incident*
    1. Type of Incident*
    2. *Workers' Compensation Claim Form (DWC1) Must be Offered.
    3. ** Workers' Compensation Claim Form(DWC1) Must be Completed
    4. Employee Information
    5. Employment Status*
    6. Part Time Only
    7. Incident Information
    8. If one was provided.
    9. Any Witnesses?*
    10. Treatment/Lost Time Information (Do Not Fill Out for Near Miss)
    11. Was First Aid Provided?*
    12. Was the Employee Seen by a Doctor?*
    13. Was This a Pre-Designated Physician?*
        1. Did the Employee Lose Work Time?*
        2. Was Employee Placed on Modified Duty?*
        3. Was Employee Offered a Claim Form DWC1?*
        4. Did Employee Fill Out Claim Form DWC1?*
            1. HR staff will use this link to upload the completed form once they verify it is complete. City employees are not required to upload the form.
            2. Do You Believe the Incident Should be Investigated by the Safety Officer or Claims Examiner?*
                1. Electronic Signature Agreement (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.
                2. Leave This Blank:

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