What type of incident are you reporting?
Vehicle/Property damage only
Vehicle/Property damage and Injury
Date of incident
Time of incident
Employee Job Title
Forward Copy To Email
Was there a witness?
Witness Contact Info
Did this incident happen in a Traffic Control Work Zone?
Street Address Line 2
State / Province
Postal / Zip Code
Affected Body Part(s)
Injury/Illness caused by
Struck by object
Struck by person
Striking against or stepping on (body)
Strains (lifting, pulling, pushing, twisting)
Cut, puncture, scrape
Slips, Trips, Falls
Heat or cold exposure
Inhalation or ingestion
Surface exposure (skin contact)
Animal or insect bite
Description of other
Property Damage Information
Description of property damage
Estimated cost to repair or replace property
Near Miss information
Description of near miss incident (how bad could it have been?)
Specific job task at time of incident
Describe how the accident/incident happened
What level of severity resulted from the incident?
Low (little or no property damage, no medical treatment beyond first-aid)
Moderate (significant property damage or injury resulting in light duty/lost work)
High (serious damage, multiple injuries or employee hospitalized)
Very High (catastrophic damage, mass casualties, fatality, amputation)
Did the injury/illness result in any of the following?
Job restrictions/transfer (cannot perform regularly assigned tasks)
Lost work days (don't include the day of incident)
Hospitalization (admitted overnight)
None of the above
Contributing Factors (select all that apply)
Lack of training
Lack of supervision
Lack of procedure
Disregard of safeguards
Lack of safeguards
Lack of PPE
Poor work site housekeeping/cleanliness
Was the employee(s) involved? (check all that apply)
Properly trained for the assigned job task
Adequately experienced for the assigned job task
Adequately supervised for the assigned job task
Involved in prior safety related incidents
List any APPLICABLE training and/or work experience
List any previous safety related counseling
How often is this most likely to happen again?
Rarely (once or twice a year)
Occasionally (more than twice a year)
Frequently (once a month or more)
Corrective action(s) taken to prevent or reduce future occurrence
Corrective action(s) completed on or target date for completion
Report submitted by (Supervisor level or above)
Has a worker's compensation claim been started for this injury/illness?
Has a Vehicle Accident Report been submitted to Risk Management?
Was the city employee given a citation for the vehicle accident?
Was any of the vehicles involved in the vehicle accident towed away from the scene?
Was anyone involved in the accident taken to the hospital or other medical treatment facility for injuries related to the accident?
Was the employee taken for a post-accident alcohol and drug testing in accordance with city policy?
Did a supervisor speak with the employee after the accident and determine there was no reasonable suspicion of impairment from alcohol or drugs involved?
By checking this box, I certify that the information I have entered is true and correct to the best of my knowledge and belief.
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