Teammate Handbook Cover

Were other individuals injured/ill due to this event?

Yes

No

If the object was a mechanical apparatus or vehicle, which part caused the injury? (Such as gear, pulley, motor, etc.)

Did employee receive medical attention?

Yes

No (If yes, indicate where medical attention was

received).

Was another person responsible for injury? Yes ____ No If yes, who?

In circumstances involving motor vehicle accidents, was a police report taken? _____Yes ______ No

Can you recommend ways to prevent the incident from reoccurring?

Name(s) of Witness (es)

Was appropriate safety equipment provided?

Was the employee using the mechanical or other safe guards when the incident occurred?

What is the Department doing to prevent such an incident from happening again?

If the employee has restrictions for returning to work, is modified duty available (please explain)?

Supervisor’s Signature:

Print Name:

Date:

Director’s Signature:

Date:

PLEASE BE SURE TO ADVISE HUMAN RESOURCES WHEN THE INJURED EMPLOYEE IS UNABLE TO WORK OR WHEN THE INJURED EMPLOYEE RETURNS TO WORK

This form must be forwarded to Human Resources within 24 hours of incident to hr @morganhill.ca.gov.

Revised 01/22