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.

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Who was Injured, What Happened and When?

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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?  :  
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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*
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Type of Injury*
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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?*
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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.*