Injury Report (City of Davenport Employees/Internal Use Only)

 Step 1 of 1

Use this form to report employee* injury during job performance. 

A copy of the completed form is automatically submitted to Risk Management for processing, to assigned Department/Division staff and the employee's direct Supervisor for safety measurement and potential investigation and/or corrective action.

The Confirmation Page received by assigned staff includes fields to record other information collected about the injury and corrective action, if any/needed.  If corrective action is identified, the form will be signed by the employee and Department/Division Manager or assigned staff and a copy placed in the employee's Human Resources file. 

*Form not for use by Police and Fire. 

Questions and Answers About Workers' Compensation Law For Injured Workers ( )

* Denotes a required field

Provide contact information for the Supervisor or authorized individual recording the First Report of Injury with the injured employee.


Who was Injured, What Happened and When?

Is the activity part of the employee's normal job duties?*
What date and time did the injury occur?*
 What date and time did the injury occur?  :  
What date and time is the report being submitted?*
 What date and time is the report being submitted?  :  
What time did the employee's shift begin?*
 What time did the employee's shift begin?  :  
Was the employee wearing appropriate PPE?*
Did the employee follow standard operating procedure, SDS, and/or manufacturer written instruction?*

Provide specifics about the injury

Part(s) of Body Injured*
Type of Injury*

Describe what type of treatment the employee received

Treatment Type*
Location of Treatment*

Describe the employee's status at the time of the injury.

Working Out of Class?*
Working Overtime?*
Does employee have secondary employment?*
Is the employee suspected to be under the influence of drugs or alcohol? If yes, Supervisor/authorized individual acknowledges appropriate steps will be taken.*