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

  1. Routed to Operations Chief and Fire Administration, 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 Napa Fire Department employees only. All other city employees please follow the normal reporting process.
  3. Is This an Update of a Previously Reported Incident*
  4. Type of Incident*
  5. *Workers' Compensation Claim Form (DWC1) Must be Offered.
  6. ** Workers' Compensation Claim Form(DWC1) Must be Completed
  7. Employee Information
  8. Employment Status*
  9. Shift Type
  10. Incident Information
  11. Any Witnesses?*
  12. Treatment/Lost Time Information (Do Not Fill Out for Near Miss)
  13. Was First Aid Provided?*
  14. Was the Employee Seen by a Doctor?*
  15. Was This a Pre-Designated Physician?*
  16. Did the Employee Lose Work Time?*
  17. Was Employee Placed on Modified Duty?*
  18. Was Employee Offered a Claim Form DWC1?*
  19. Did Employee Fill Out Claim Form DWC1?
  20. Fire Administration staff will use this link to upload the completed form once they verify it is complete. Operations staff are not required to upload the form.

  21. Do You Believe the Incident Should be Investigated by the Safety Officer or Claims Examiner?*
  22. Leave This Blank:

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