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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.
If Yes, Fleet Service Request Required. (Clicking Yes will display link)
Complete Service Request before proceeding further. Number required below on this form.
The employee MUST fill out a Supervisor's Report of Work-Related Near Miss, Injury, Illness, or Exposure Form (Clicking Yes will display link)
Any and all property damage must be listed to include an Employee's private property if any.
Please check all that apply
*If a witness was involved, please complete a Witness Statement Form.
Must be filled out by the 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.
This field is not part of the form submission.
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