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Employee Incident Report
This entire form needs to be completed by you and/or your supervisor. This form must be submitted to Human Resources within 24 hours of the incident.
This form shall be completed any time a County employee has:
Sustained an injury while on the job,
Had a work-related exposure incident,
Been witness to a near miss incident,
or sustained a work-related illness.
This form is important as it ensures the County's compliance and accuracy in:
OSHA reporting, L&I Claims, and Safety Committee review.
Please note: If the incident caused (or has the potential to cause) injury or damage to another employee, member of the public, vehicle, property, or equipment, you must complete the "Grant County Risk Management General Liability Loss Notice Form" immediately. This form activates the County's insurance and risk management reporting requirements. This form is available in both this app and on the Grant County Intranet.
*If yes, employee shall complete the "Grant County Risk Management General Liability Loss Notice Form" immediately.
* indicates a required field