GVR5 Employee Report of Incident Form

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Must be submitted by employee regardless of seeking medical attention or not.

Name: *

Position with the school district: *

Your assigned school or building: *

Date of Incident: *

YYYY

Time of Incident *

Time

Time you began work that day *

Time

Location of incident: *

What were you doing when the incident occurred and HOW did it occur? *

If injury occurred, describe in detail and include the part of the body affected: *

Please list any witnesses: *

Treatment provided: *

None needed

Clinic

Hospital/ER

First Aid

Other:

Accident was: Preventable or not preventable? and state why: *

How can this incident be prevented in the future? *

Any additional information relating to the incident:

By submitting this form, you accept this submittal as your electronic authorization/signature to the statements made above.

If HR has further questions, one of our staff members will be in contact with you.

Submit

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