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2. Incident Date*
   Incident Date
4. Incident Time*
   Incident Time
6. Reason for Report*
   -- Select One --AccidentUnruly-Angry personNon-ComplianceBiohazard (blood or bodily fluids)Chemical ExposureExposure to?FatalityIllnessInjuryOther
8. If other
10. Name of Officer*
12. Location
    -- Select One --CR 202CR 209CR 301CR WheelerAnnex 1st floorAnnex 2nd floorAnnex 3rd floorCourthouse 1st floorCourthouse 2nd floorCourthouse 3rd floorLaw & Justice 1st floorLaw & Justice 2nd floorWheeler CampusEphrata CampusFairgroundsOther
14. If other
16. Describe what happened.
18. If an injury or exposure occurred, what part of the body was affected
20. Did you go to the Doctor*

    1. Yes
    2. No
22. If treatment was provided, in what clinic, by what doctor
24. Names of any witness
26. Was the accident/injury caused by a County employee

    1. Yes
    2. No
28. If yes, employee name
30. Emergency steps that were taken
32. Were emergency services contacted (fire/police/ems)

    1. Yes
    2. No
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field