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

2. Routed to Operations Chief and Fire Administration, 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 Napa Fire Department employees only. All other city employees please follow the normal reporting process.
6. Todays Date*
   Todays 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*
24. Division*
26. Employment Status*

    1. Full-Time
    2. Part-Time
    3. Limited Term
27. Shift Type

    1. 24 Hours
    2. 40 Hours
    3. Part-Time
28. Hours/Week (Part-Time Only)
32. Incident Information
34. Incident Date & Time*
    Incident Date & Time

    Incident Date & Time
35. Report Date*
    Report Date
36. Incident Number*
38. Incident Address*
39. City*
40. Zip Code*
42. Any Witnesses?*

    1. Yes
    2. No
43. Witness Name(s)
45. Detailed Description of Incident*
47. Describe Injury to Body Part*
49. List Equipment, Materials, or Chemicals Involved in the Incident*
51. What Steps Have Been Taken to Avoid Future Occurrences?
53. Treatment/Lost Time Information (Do Not Fill Out for Near Miss)
55. Was First Aid Provided?*

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

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

    1. Yes
    2. No
64. Did the Employee Lose Work Time?*

    1. Yes
    2. No
65. If Yes, Last Work Date*
    If Yes, Last Work Date
66. Return Date (If Known)
    Return Date (If Known)
68. Was Employee Placed on Modified Duty?*

    1. Yes
    2. No
69. Was Employee Offered a Claim Form DWC1?*

    1. Yes
    2. No
71. 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 Battalion Chief will ensure that this form is given to Fire Administration. Fire Administration will upload the completed form to the ESO Incident Report (Ops personnel not required to upload form).
73. Did Employee Fill Out Claim Form DWC1?

    1. Yes
    2. No
75. (Fire Admin Staff only): Upload Filled Out DWC1 Form

    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.

77. Do You Believe the Incident Should be Investigated by the Safety Officer or Claims Examiner?*

    1. Yes
    2. No
79. If Yes, Please Describe Your Concern:*
81. Your Supervisor *
    -- Select One --Operations Division Chief BerensBattalion Chief CorteseBattalion Chief GilbertBattalion Chief RhodesAdministrative Battalion Chief BecerraCaptain AimarCaptain BaraccoCaptain BurgessCaptain CaldwellCaptain ChagonjianCaptain ChamnessCaptain CroweCaptain DavisCaptain DombrowskiCaptain GenaroCaptain JonesCaptain KochCaptain LangfordCaptain MortimoreCaptain OlivaCaptain UlitinCaptain VoglerGreg FortuneShuree Egloff

    You Supervisor Will Receive This Request

83. Date
    Date
85. Your Battalion Chief (Operations Only)
    -- Select One --Administrative Battalion Chief BecerraBattalion Chief CorteseBattalion Chief GilbertBattalion Chief Rhodes

    Your Battalion Chief Will Receive This Request

Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field