Employee Incident Report

For EXTERNAL Incidents (involves community member injury or damage to private property), the reporting employee must send the following information ASAP:

Full description of Incident including a summary of what was discussed with community member
Names of other City staff involved
Photos of damage, if applicable
Video or link to video if available
Supervisor name and signature

For INTERNAL Incidents (involves City property damage caused by an employee or an outside party), reporting employee must send the following information ASAP:

Photos of damage, if applicable
Repair/replacement estimates
Repair/replacement invoices
Staff labor costs and calculations if applicable
Supervisor name and signature

Date	Time Format Example 06:45am or 12:36 pm (leave blank if unknown)
Address	City
State	Zip

Department	Selected Department ID
Selected Department Name	Service Area
Streets Email	Police Email
L&P Email

Please enter the information for the employee involved in the incident.

Is the person a City employee?

First Name

Last Name

Employee Name Please enter your last name for improved search	Email
Employee ID

Supervisor Name	Supervisor Email
Additional Employee to Receive Copy of Form (If applicable)	Additional Employee Email
Supervisor ID

Name	Email
Reporter ID

Your Supervisor's Name	Your Supervisor's Email
Reporter Supervisor ID

First Name of Community Member Involved	Last Name of Community Member Involved Please enter "Unknown" if not known.
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Please leave blank if unknown

Healthcare Provider Name

Healthcare Provider Location

Make Enter "Unknown" if not known	Model
Year

First Name	Last Name
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Please leave blank if unknown

First Name	Last Name
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Please leave blank if unknown

First Name	Last Name
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Please leave blank if unknown

First Name	Last Name
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Please leave blank if unknown

Make Enter "Unknown" if not known	Model
Year

Back Lower	Back Upper	Chest and/or ribs	Face	Head
Hip	Left Ankle	Left Arm	Left Eye	Left Foot
Left Hand	Left Knee	Left Leg	Left Shoulder	Mouth
Neck	Right Ankle	Right Arm	Right Eye	Right Foot
Right Hand	Right Knee	Right Leg	Right Shoulder	Toe

Employee Incident Report

(Do NOT use for work related injuries/exposures)