Employee Incident Report Form
FORM MUST BE COMPLETELY FILLED OUT
**Form should be filled out by injured employee. If injured employee is unable to fill out form with-
in specified time period, the immediate supervisor should fill it out to the best of his/her ability.
Please use your discretion.**
Check box if completing form FOR injured employee
Section 1: EMPLOYEE INFORMATION
Employee Name: Date of Birth:
Home Address: Telephone Number:
Job Title: Department: Employee ID #:
Check All That Applies: Full Time Part Time Temporary Contract Employee
Section 2: INCIDENT INFORMATION
Incident Date: Time of Incident: am/pm Time Shift Began: am/pm
Incident Reported to: Date/Time Incident Reported:
Part of Body Injured (specific):
Type of Accident:
Slip/Trip/Fall Extreme Temperature Repetitive Motion Material Handling
Cuts/Sharps Striking an Object Abrasion/Bruise Blood Borne Exposure
Other:
Injured on County Proper- ty: Yes No (Specify Address)
Incident Location (i.e. lobby, hallway, etc):
Action Taken: First Aid Employer Clinic Hospital (Specify)
# of Employees Involved: # Injured/Ill: # Fatalities:
How Did the Incident Occur. List safety equipment in use (if any) and specifics as to how the injury occurred. Attach photos,
sketches, and/or second page if necessary.
FORM MUST BE COMPLETELY FILLED OUT
SECTION 3: WITNESS INFORMATION (If, any)
Witnesses (Name & Phone Number):
WITNESS (If Any) Please Fill Out Supplemental Witness Form
Section 4: CORRECTIVE ACTIONS (To be filled out by immediate supervisor)
What Action Can Be Taken to Prevent Incident Reoccurrence?
Equipment/Machinery Modification or Maintenance Improve Personal Protection
Improve Design/Construction Enhance Training and Instruction
Change to Work Procedure Use of Safer Material
Improve Housekeeping Re-Training
Improve Work Organization
Other:
Specify Measures Already Taken:
Comments:
Section 5: SIGNATURES
Name of Immediate Supervisor (Printed): Phone #:
Signature of Immediate Supervisor: Date:
Name of Department Head: Phone #:
Signature of Department Head: Date:
AUTHORIZATION FOR PATIENT RECORDS
I, the undersigned, do hereby authorize by my signature on this injury and illness report, any hospital, physi-
cian, or other person who has attended me or examined me regarding the injury/illness described above to
furnish the County of Macomb, or its representative any and all information with respect to this injury/illness
and medical history, consultation, prescription, or treatment, and copies of all hospital or medical records of
prior injuries/illnesses similar to this one. A photostatic copy of this Authorization shall be considered as ef-
fective and valid as the original.
Signature of Employee: Date:
Please immediately scan and email these documents to:
employeeincidentreport@macombgov.org or fax them to (586)469-6974 and forward the originals
via interoffice mail to Human Resources and Labor Relations.
These forms must be returned IMMEDIATELY after completion or within 24 hours of Incident
