Teammate Handbook Cover

CITY OF MORGAN HILL INCIDENT REPORT

This report must be completed and returned to Human Resources within 24 hours of any type of injury, regardless of how minor. Complete all blanks below.

EMPLOYEE SECTION

Employee Name:

Job Title:

Employee’s Home Address:

Home Phone:( )

Work Phone:(

)

Message Phone (or cell) : (

)

Date of Incident:

Location of Incident:

Time of Incident: ______a.m.

p.m.

What time did you begin work? ______a.m.

p.m.

How did incident occur? (Be specific)

I have injured the following body parts: To whom did you report this injury/incident: Date this injury/incident was reported:

I feel

I DO NOT need medical treatment at this time

DO need medical treatment at this time

Employee’s Signature

Date

SUPERVISOR SECTION

Was a claim form (DWC 1) provided to the employee? Yes ______ No If yes, date provided: __________ Date this injury/incident/condition was reported to you: _______________________________________________ Was employee able to work after incident? Yes No (If no, indicate last day worked) Has employee returned to work? ____ Yes _____ No If yes, date returned to work: _____________________

Nature of injury/illness and part of body affected:

Where did incident occur? (street, address, city and county)

Department where injury occurred: _____________________________________________________________ Were other employees injured/ill due to this event (please identify)?

What was the employee doing when injured? (Be specific: identify tools, equipment, and/or material employee was using).

Object/substance that directly injured employee:

Did the incident involve a hazardous material (if yes, please describe/identify)?

- over -