Employee Incident Report
Please complete this form, in full, any time an employee is injured (Submit within 24 hours of injury).
Name
*
First Name
Middle Name
Last Name
Date of Injury
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Select the response(s) that apply to you:
*
Pro-Act
Ukeru
Therapeutic Options
None/ Training Expired
School/Building
*
Please Select
Ben Franklin Elementary School
Century Elementary School
Child Nutrition
Community High School
Discovery Elementary School
Elroy Schroeder Middle School
Grand Forks Central High School
Head Start
J Nelson Kelly Elementary School
Lake Agassiz Elementary School
Lewis & Clark Elementary School
Mark Sanford Education Center
Nathan Twining Elementary and Middle School
Phoenix Elementary School
South Middle School
Red River High School
RMAC
Valley Middle School
Viking Elementary School
Wilder Elementary School
Winship Elementary School
What is your position?
*
Witness Name
Was this injury a result of a student behavior?
*
Yes
No
If so, what are the students initials
First & last initial of student
Will medical treatment be sought? (If yes, submit Workability Report from your Doctor's visit to HR) *Please note, your doctor must use the GFPS, DMP (Altru or Sanford) first.
*
Yes
No
Clinic/Hospital Name
City/State
Did you go to the Emergency Room?
Yes
No
Birthdate:
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Nature of Injury - Explain what was taking place before AND during the incident:
*
Body Part(s) Injured: (Ex: Left shoulder, right middle finger, neck)
*
Nature of injury or illness? (Ex: burn, broken bone, contusion)
*
I notified my Principal/Supervisor
*
Yes
No
Submit
Should be Empty: