Public Safety

EMPLOYEE INJURY REPORT FORM

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 鈥淎CCIDENT/INCIDENT Employee Statement鈥� 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.