Employee Incident Report Part 2

Employee report code * Required

Enter the code you received in email. It will start with the employee's last name and have a 5 digit number after it.
District * Required
Date incident investigated * Required
MM slash DD slash YYYY
Injured employee's name * Required
First Last
Employee email * Required
Employee's reported date of incident * Required
MM slash DD slash YYYY
Describe reported incident, per your findings * Required
Describe what was found to be unsafe
Employee actions, equipment, lighting, clutter, etc.
Equipment damaged
If yes, describe equipment damage
Follow up action * Required
Provide a brief description of follow up action
Follow up by

Provide name
Has employee missed work due to incident?
Last date employee worked
MM slash DD slash YYYY
Date employee returned to work
MM slash DD slash YYYY

If the employee has not returned to work, leave this response blank.
Is light duty work available?
Your name * Required
First Last
Your phone number * Required
Your email * Required
Your job title * Required

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