Personnel Injury Report
Please complete all required fields IMMEDIATELY when reporting a work-related injury. After the form is completed click the submit button at the bottom of this form.
Reference Policy 900
Employee Information
Employee Name:
*
First Name
Last Name
I am reporting a work related:
*
Injury
Illness
Employee Number:
*
Employee Email:
*
example@example.com
Employee Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Injury or Illness:
*
-
Month
-
Day
Year
Date
Time of Injury:
*
Location of Injury Occurred (Station number or Incident address):
*
Did you seek medical attention:
*
Yes
No
If yes, where:
*
Physician's Name:
*
Loss of Work:
*
Yes
No
Unknown at this time
If yes, how many hours or days?
*
What were you doing at the time of the injury (Be specific - for example, using hand tools or lifting a patient)?
*
Describe in detail how the injury occurred, and what injury you recieved. (Tell what happened and how)
*
Were you in a District Vehicle?
*
Yes
No
Were seat belts being worn?
*
Yes
No
Contributing Circumstances - check all that apply:
*
Dark
Poor Lighting
Rain
Snow
Slippery
Tight Area
None Apply
Signature
*
Once this form is completed you will be directed to the PIIERS login. This is optional, but highly recommended that you fill this document out as well.
Captain's email:
*
example@example.com
Submit
Submit
Should be Empty: