Action Center / Injury Report (City of Davenport Employees/Internal Use Only) / Davenport, Iowa

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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 ( http://www.iowaworkforce.org/wc/qa14-15.pdf )

* Denotes a required field

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

Supervisor Email Address*

Who was Injured, What Happened and When?

Injured Employee's Full Name*

Employee's Job Title*

Employee #*

Please Do Not Complete The Following Field

Employee narrative of what their injury is and how it happened.*

What was the incident location? What were site conditions like (slippery, spill, etc.)? Include Street Address (Street and Block and/or Facility Name).*

What activity/task was the employee engaged in at the time of injury?*

Is the activity part of the employee's normal job duties?*

Yes No

What date and time did the injury occur?*

MonthDay Year,

HourMinute : AM/PM

What date and time is the report being submitted?*

MonthDay Year,

HourMinute : AM/PM

What time did the employee's shift begin?*

MonthDay Year,

HourMinute : AM/PM

Did the incident occur before, during or after the employee's shift?*

Was the employee wearing appropriate PPE?*

Yes No

Did the employee follow standard operating procedure, SDS, and/or manufacturer written instruction?*

Yes No

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

Working Out of Class?*

Yes No

Working Overtime?*

Yes No

Did injury occur during any of the following operations?*

Does employee have secondary employment?*

Yes No

Is the employee suspected to be under the influence of drugs or alcohol? If yes, Supervisor/authorized individual acknowledges appropriate steps will be taken.*

Yes No

Abdomen (internal or external)	Digestive System	Neck	Mental Health
Arm(s) (including wrist)	Ear(s), Internal and External Including Hearing	Hand(s) and/or Finger(s)	Shoulder(s)
Back (muscles, spine, spinal cord)	Eyes	Head (not face, eye(s), internal ears)	Respiratory System
Chest (ribs, internal organs)	Face (nose, mouth, lips, teeth)	Hip(s)	Body Part not otherwise classified
Circulatory System	Foot, Feet and/or Toe(s)	Leg(s)

Abrasion/Scratch	Contusion/Bruise	Electrical Shock/Electrocution	Fracturer/Dislocation	Numbness/Tingling	Sprains/Strains
Amputation	Crush	Exposure to Body Fluids	Heat/Cold Injury or Illness	Respiratory Problem	Traumatic Event
Burn	Dermatitis/Rash	Foreign Body (eye)	Inflamation/Swelling	Sore/Stiff

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

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

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?

Provide specifics about the injury

Describe what type of treatment the employee received

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

Dialog Title