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Instructions for Employees
Complete this form within 48 hours of incident.
All employees are required to report all injuries/accidents
  • Contact the Department of Public Safety immediately
  • Notify your supervisor as soon as possible
  • Complete the “ACCIDENT/INCIDENT Employee Statement” form (SGWCP-2) below and submit within 48 hours of incident.
  • Employees are to go to a Fast Med Urgent Care location and present this form



Public Safety Notified?*
Supervisor Notified?*
Name of Supervisor Notified of Injury
Weather conditions at time of incident*
Be as specific as possible.
Be specific and detailed.
Was medical treatment required?*
List anyone who may have witnessed to accident/incident.