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2. Routed to Risk Management & Human Resources, CC'd to Supervisor
   CC'd Recipient: This Form is For Awareness Only, No Further Action Required.
4. 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
6. Today's Date*
   Today's Date
7. Is This an Update of a Previously Reported Incident*

   1. Yes

   1. No
9. Type of Incident*

   1. Near Miss - No Injury or Property Damage but Noteworthy for Future Preventative Actions

   1. Minor Injury/Exposure* - Minor Injury That Requires No Professional Medical Care and Does Not Result in Lost Time

   1. Injury or Illness** - Work-Related Injury or Illness That Requires Professional Medical Care and/or Results in Lost Time

   1. Exposure** - Work-Related Exposure That Requires Professional Medical Care and/or Results in Lost Time
11. *Workers' Compensation Claim Form (DWC1) Must be Offered.
13. ** Workers' Compensation Claim Form(DWC1) Must be Completed
17. Employee Information
19. First Name*
20. Last Name*
22. Job Title*
23. Department*
    -- Select One -- Public WorksHuman ResourcesParks & RecreationFinanceCommunity DevelopmentPolice DepartmentFire DepartmentUtilitiesCity ManagerCity AttorneyCity Clerk
24. Division*
26. Employment Status*

    1. Full-Time

    1. Part-Time

    1. Limited Term
27. Hours/Week
    Part Time Only
29. Employee Phone Number:*
31. Employee Email Address:
35. Incident Information
37. Incident Date & Time*
    Incident Date & Time

    Incident Date & Time
38. Report Date*
    Report Date
39. PD or FD Incident Number
    If one was provided.
41. Incident Address*
42. City*
43. Zip Code*
45. Any Witnesses?*

    1. Yes

    1. No
46. Witness Name(s)*
48. Witness statements may be uploaded here.
50. Detailed Description of Incident*
52. Describe Injury to Body Part*
54. List Equipment, Materials, or Chemicals Involved in the Incident*
56. What Steps Have Been Taken to Avoid Future Occurrences?
58. Treatment/Lost Time Information (Do Not Fill Out for Near Miss)
60. Was First Aid Provided?*

    1. Yes

    1. No
61. If Yes, First-Aid Provider's Name?*
63. Was the Employee Seen by a Doctor?*

    1. Yes

    1. No
65. If Yes, Physician's Name, Address, and Phone Number*
67. Was This a Pre-Designated Physician?*

    1. Yes

    1. No

    Employees are must treat with Kaiser (with the exception of emergencies) unless they have a predesignation on file with Human Resources.

69. Did the Employee Lose Work Time?*

    1. Yes

    1. No
70. If Yes, Last Work Date*
    If Yes, Last Work Date
71. Return Date (If Known)
    Return Date (If Known)
73. Was Employee Placed on Modified Duty?*

    1. Yes

    1. No
75. Was Employee Offered a Claim Form DWC1?*

    1. Yes

    1. No
77. Click Link Below for Downloadable DWC1 Form
    DWC-1 Form

    When filled out, this form must be downloaded, printed out, filled out completely, and signed. The Supervisor must ensure that this form is given to Human Resources/Risk Management.

79. Did Employee Fill Out Claim Form DWC1?*

    1. Yes

    1. No
81. Upload Filled Out DWC1 Form*

    You may attach the completed DWC1 form here or email it directly to [email protected]

83. Do You Believe the Incident Should be Investigated by the Safety/Risk or Claims Examiner?*

    1. Yes

    1. No
85. If Yes, Please Describe Your Concern:*
87. Supervisor submitting this form*
    -- Select One --Division Chief BerensJoni BrownRobert "Dean" HannaBattalion Chief CorteseBattalion Chief GilbertWarren CraigBattalion Chief RhodesCaptain BaraccoBattalion Chief BecerraCaptain BurgessCaptain CaldwellCaptain CroweElizabeth CroweCaptain DavisCaptain JonesCaptain LangfordCaptain MortimoreCaptain OlivaSamuel GlennCaptain VoglerGreg FortuneShuree EgloffMichael BarrettSteve PotterTony ValadezJoy RiesenbergHernando GuillemSabrina DanielsJason WilliamsSabrina FloresJason BerensZach CurrenStephanie GaulSteve PotterVincent SmithBreyana BrandtAnette HeunScott NielsenTracy ThompsonMJ TuerosKen RutherfordChuck SamsonJose AlvarezBrian DonahueBrandon AlvesCaitlin SaldanhaJessie GoochSara Gallegos-AscencioJoanne FabiaTiffany CarranzaAlexandra "Ali" KoenigDan OppermanDavid YoudellDerek TrayaHannah RamirezLiz HabkirkSarah FreemanJeffrey GittingsJohn HeddermanKatrina GregoryKelly AbernathyLinda ButtonPeter "Pete" HangenChase HaagGary PitkinGus UllothHeath MorrisonJennifer GonzalesKristofer JennyNicholas DalessiPeter "Pete" PiersigEdward "Ed" MooreHeather MaloneyJose "Joe" GallegosJoseph CarrionJulie Lucido Julio Carillo-ElizaldeMagdiel FrayreAfton PinneyPeter BrestakRichard HansenTimothy WoodChristopher "Chris" ShoopDavid HightDouglas De MasterErin KebbasJoy EldredgeKevin MillerPatrick CostelloPhilip "Phil" BrunKen HurstSabrina WolfsonRobert JanowskiVincent WildermanJosh StokesKelly TrujilloAlexander IslerBecky AbramsDominic DeguilioMarcus MartinezAdam DavisTyler OlsonAndy OrosSean UlitinDustin DoddTommy KeenerFabio RodriguezBrett MuratoriTricia Seyler-CampbellOmar SalemKeri SedgleyBrian DonahueGarrett SmithAaron MedinaDominic DeguilioKevin SkillingsLee-Ann CroweSarah FreemanLupe CurielChristopher PachecoVeronica RodriguesRajneil PrasadDominic DigloriaJessica LoweDavid OrozcoMolly RattiganMatthew PriceSamantha Pascoe

    The Supervisor Will Receive This Request in an email

89. 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.

    1. I agree.
91. Supervisor's Electronic Signature*
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field