GVR5 Employee Report of Incident Form
Must be submitted by employee regardless of seeking medical attention or not.
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Name: *
Position with the school district: *
Your assigned school or building: *
Date of Incident: *
Time of Incident *
Time you began work that day *
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: *
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.
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