Employee Incident Report

FOR REPORTING WORK-RELATED INJURIES/ILLNESSES/NEAR MISSES
(This is NOT a Workers’ Compensation benefits claim form)

Personal Details

Page 1 of 5

First Name*field type single line
Input blocked. Maximum character limit of 35 characters reached.
MIddle Initial*field type single line
Enter NA for no middle name
Input blocked. Maximum character limit of 2 characters reached.
Last Name*field type single line
Input blocked. Maximum character limit of 50 characters reached.
Suffixfield type single line
Input blocked. Maximum character limit of 4 characters reached.
Genderfield type radio button
GenderMaleFemale
SSN - Last 4 numbers onlyfield type single line
Input blocked. Maximum character limit of 4 characters reached.
Date of Birth*field type date
Email*field type email

Street*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State*field type single line
Input blocked. Maximum character limit of 2 characters reached.
Zip Code*field type single line
Input blocked. Maximum character limit of 5 characters reached.
Primary Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Extensionfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Primary Phone Type*field type radio button
Primary Phone TypeCellHomeWork
Optional Phonefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Extensionfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Optional Phone Typefield type radio button
Optional Phone TypeCellHomeWork

ESDfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Employer*field type drop-down
Assigned Districtfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Job Title*field type drop-down
Other Job Titlefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Department*field type drop-down
Schedule (i.e. 7-3:30 M-F)field type single line
Enter schedule for date of incident if shift varies
Input blocked. Maximum character limit of 4000 characters reached.
Supervisor's Name*field type single line
Principal, Asst. Director, Director or Manager
Input blocked. Maximum character limit of 4000 characters reached.
Supervisor's Titlefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Supervisor's Email*field type email
Supervisor's Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Supervisor's Extensionfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Do you have additional employment?field type radio button
Do you have additional employment?YesNo
Enter Additional Employer(s)field type multi line

Date of Incident*field type date
Time of Incident*field type time
Cause of Incident*field type drop-down
Building Incident Occurred At*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Location Incident Occurred At*field type drop-down
Other Locationfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
HOW DID THE INCIDENT OCCUR? WHAT WAS THE ACTIVITY AND ANY TOOLS, EQUIPMENT, OR MATERIALS YOU WERE USING? (Example: I was opening a box of paper using a razor blade. The razor blade slipped on the surface of the box, and cut my right index finger) DO NOT USE STUDENT NAME(S) OR INITIALS (Example: I was working with student when they threw a ball and it jammed my finger)
Description*field type multi line
Injuries
×
- Body Part Injured*field type drop-down
- Sidefield type checkbox
  SideLeftRight
- Type of Injuryfield type drop-down
Add Another Injured Body Part
Did you report the incident?field type radio button
Did you report the incident?YesNo
Incident Reported To:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date Incident Reportedfield type date
Was there a witness?field type radio button
Was there a witness?YesNo
Witness(es) Name(s)field type single line
Input blocked. Maximum character limit of 4000 characters reached.

Injuries