Employee Incident Report

Your First and Last Name

Your Job Title

Your Birth Date

Full Social Security Number

Your Date of Hire

Your Phone Number

Your Work Email Address:

Your Street Number

Your Street Name

Apt #

Your Zip Code

Date of Incident

Radio buttons

AM PM

Specific Incident Location (within the center, home or van) Example: kitchen, west entrance, lunch area, van exit etc...

Client Initials (if client caused injury) - If Not Enter: n/a

Did the injury occur during PCM procedures?

Yes No

Was Safety Equipment Provided?

Yes No

If yes, was it used?

Yes No

Description of Incident

Mark The Areas On The Image Where You Are Experiencing Symptoms

IF YOU SELECTED NO TREATMENT OR MINOR ON-SITE AND LATER DECIDE TO SEEK MEDICAL TREATMENT YOU MUST EMAIL WORKERSCOMP@COLORADOBEHAVIOR.COM IMMEDIATELY.

Today's Date

Eyewitness Full Name - If None Enter: n/a

Eyewitness Comments

Name of Supervisor Notified

Date Supervisor Was Notified

Supervisor Review Completed:

*Supervisor/Management Use Only"

Any Follow Up Actions Needed:

*Management/HR Use Only*

IF THE INCIDENT WAS SEVERE, PLEASE TAKE PHOTOS OF THE INJURY SITE AND THE CAUSE OF THE INJURY AND ATTACH THEM TO THIS REPORT

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