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Supervisor's Report of Incident Form

  1. Supervisor's Report of Incident Form

    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.

  2. Check as Appropriate*
  3. City Fleet Vehicle/Equipment Damaged?*

    If Yes, Fleet Service Request Required. (Clicking Yes will display link)

  4. Employee Injury?*

    The employee MUST fill out a Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form (Clicking Yes will display link)

  5. Private Property Damage?*

    Any and all property damage must be listed to include an Employee's private property if any.

  6. PART A: Contact Information of Person Involved
  7. Person Involved is a:*
  8. PART B: Parent/Guardian Contact information (If Minor)
  9. PART C: Details of Incident
  10. Staff Member in charge or on duty:
  11. If person involved was NOT injured, please skip to Part E
  12. Indicate type of care
  13. Injured Person
  14. Injured person was
  15. PART D: Bodily Injury
  16. Indicate which part of the body was inured

    Please check all that apply

  17. Upper Body (Left)
  18. Upper Body (Right)
  19. Lower Body (Left)
  20. Lower Body (Right)
  21. Other
  22. PART E: Witness Information
  23. Witness #1
  24. Witness is a:
  25. Witness #2
  26. Witness is a:
  27. Witness #3
  28. Witness is a:
  29. PART F: Other Information
  30. Must be filled out by the Supervisor

  31. PART G: Preparation and Review
  32. Supervisor Name:
  33. Department Head Name:
  34. Director Name:
  35. Report prepared by:
  36. Electronic Signature Agreement*

    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.

  37. Leave This Blank:

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