Office of Risk Management
Incident, Accident or Unsafe Condition Report
< Print Form to Complete by Hand
Accident Information
Department:
* Required
REQUIRED
Agency/Division:
* Required
REQUIRED
Date of Accident:
* Required
REQUIRED
Time of Accident:
am
pm
* Required
REQUIRED
Type:
Accident
Incident
Unsafe Condition
Location of Accident, Incident, or Unsafe Condition:
* Required
REQUIRED
Employee Completing Report
Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Title:
* Required
REQUIRED
Employment Status:
Temporary
Permanent
* Required
REQUIRED
Work Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Person Involved in the Accident or Incident
Name:
* Required
REQUIRED
DOB:
(MM/DD/YYYY)
* Required
REQUIRED
(mm/dd/yyyy)
Invalid Date
Address:
* Required
REQUIRED
Home Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
Occupation:
* Required
REQUIRED
Business Address:
* Required
REQUIRED
Business Phone:
Ex. (555)555-5555
* Required
REQUIRED
Invalid Phone No. Please use (555)555-5555 format.
What was the person involved doing at the time of the accident or incident:
Injury
What was the nature and extent of the injury?
Was first-aid administered?
Yes
No
If yes, by whom?
Describe the type of first-aid treatment given:
Was medical treatment administered?
Yes
No
If yes, by whom?
Name and address of medical facility:
Did accident result in fatality?
Yes
No
* Required
REQUIRED
Property Damage
Owner:
(include address and phone)
* Required
REQUIRED
Damage Description:
(include estimated repair costs)
* Required
REQUIRED
Witnesses
Name:
(include address and phone)
Name:
(include address and phone)
Accident Description
Describe in detail:
* Required
REQUIRED
Include Pictures Here:
Legal
Was Law Enforcement Contacted?
Yes
No
* Required
REQUIRED
Name of Law Enforcement Agency:
Signature
Signature:
(type name in signature box)
* Required
REQUIRED
Date:
* Required
REQUIRED
