Incident Report

INCIDENT REPORT

All incidents must be reported to the City Clerk/Personnel within 24 hours
- Date Reported to City Clerk
  
  MonthDayYear
  (City property damage, private property damage, citizen injury)
- Date Reported to Personnel
  
  MonthDayYear
  (Employee property damage)
- When did the incident occur?
  
  MonthDayYear
  
  Hour MinutesAM/PM Option
- When was the incident reported to staff?
  
  MonthDayYear
  
  Hour MinutesAM/PM Option
- Location / Facility
  If incident did not occur at a City Facility, please select a blank row and enter the location name and address in the "Detailed Location" section.
- Detailed Location of Occurrence
  Be as detailed as possible. EXAMPLE: north basketball court, west field, YAC Cafe, 1st mile on Cobal Trail, NW corner of Padua Room, etc.
- Reporting Employee's Name
- Reporting Employee's Title
- What is your Department / Division
- Your City Desk Phone Extension
  3 digits
- Description of Incident (Select all that apply)
- Were the police notified?
- Was a police report taken?
- What was the police report or call log number?
- Were photos taken?
- Injured Party's Name
  If unknown, please write "Unknown" or "Refused to Provide"
- Age
- Address
  
  Home Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  Format: (000) 000-0000.
- Cell/Other Phone
  Format: (000) 000-0000.
- Medical Treatment Required?
- Emergency Medical Treatment Required?
- Name and Address of Medical Facility
  If provided
- Follow-Up Treatment Required?
- Briefly Describe Injury/Illness and Part of Body Affected
  Be as detailed as possible. Make sure to indicate left or right, if necessary. Do not guess.
- Select type of property damage:
- Date
  
  MonthDayYear
- Time
  
  Minutes
  
  AM/PM Option
- Owner's Name
- Address
  
  Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  Format: (000) 000-0000.
- Cell/Other Phone
  Format: (000) 000-0000.
- Was the owner notified?
- How was the owner notified?
- Was a City employee involved in causing the damage?
- Are there any employee trainings that relate to this situation?
- If the incident involved property damage or injury, did the employee undergo a same-day drug test?
- Drug testing comments, if any:
- Was the employee referred anywhere? If so, please describe:
- Date of Referral:
  
  MonthDayYear
  Date
- Select One:
- Involved Party's Name
- Age
- Address
  
  Home Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  Format: (000) 000-0000.
- Cell/Other Phone
  Format: (000) 000-0000.
- Did anyone (staff or member of the public) witness the incident?
- Name
- Phone
  Format: (000) 000-0000.
- Address
  
  Home Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Do you need to add another witness?
- Name
- Phone
  Format: (000) 000-0000.
- Address
  
  Home Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Do you need to add another witness?
- Name
- Phone
  Format: (000) 000-0000.
- Address
  
  Home Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- List any additional witnesses in a word document and upload at the end of this form.
- Did this incident involve an injury to a City Employee?
- DESCRIPTION OF INCIDENT
- FOLLOW UP FROM SUPERVISOR (IF NECESSARY)
- EMPLOYEE/INJURED PARTY STATEMENT: Describe what you were doing at the time of the incident.
- EMPLOYEE/INJURED PARTY STATEMENT: Describe how the incident occurred, including use, if any, of equipment, material or chemical(s) at time of incident and what, if any, actions were taken following incident.
- SUPERVISOR STATEMENT: Describe what the person was doing at the time of the incident
- SUPERVISOR STATEMENT: Describe how the incident occurred, including use, if any, of equipment, material or chemical(s) at time of incident and what, if any, actions were taken following incident
- Upload Photos or Diagrams of Incident
  
  Cancelof
- Do you need to attach additional comments or documentation?
- Upload Additional Comments, Statements, or Documentation
  
  Cancelof
- Employee's Signature
- Date
  
  MonthDayYear
- Should be Empty:

INCIDENT REPORT