Employee Injury Form (Supervisor's Form) - Public Safety Public Safety

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Public Safety Notified?*

Yes

Injured Employee

First Name

Last Name

Department*

Date and Time of Injury/Accident*

Supervisor Notified?*

Yes

Name of Supervisor Notified of Injury

First Name*

Last Name*

Date Injury Was Reported*

Weather conditions at time of incident*

Daytime, Sunny, Dry

Daytime, Cloudy, Dry

Daytime, Cloudy, Raining, Wet

Night-time, Dark, Dry

Night-time, Lighted, Dry

Night-time, Lighted, Raining, Wet

Day-time, Snowing

Day-time, Freezing Rain

Other

Location of Incident*Be as specific as possible.

Part of Body Injured*Be specific and detailed.

Description of Accident

Was medical treatment required?*

Yes

Transported to hospital by EMS

Transported themselves to above indicated medical facility

Refused medical attention

Other

Are there any witnesses to the accident/incident? If yes, who?List anyone who may have witnessed to accident/incident.

Cause of Accident

Public Safety