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2. 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.

4. Date of Incident*
   Date of Incident
5. Time of Incident*
   Time of Incident
6. Date this form is submitted.*
   Date this form is submitted.
8. Reason for Report*
   -- Select One --AccidentBiohazard (blood or bodily fluids)Chemical ExposureExposure to (?)FatalityIllnessInjuryOther
10. If "Other" selected above, brief reason
12. Name of person submitting report.*
13. Date of Birth
    Date of Birth
15. Department
    -- Select One --AssessorAuditorCentral ServicesClerk's OfficeCommissioners OfficeCoronerDevelopment ServicesDistrict CourtFairgroundsRenewHealth DistrictHuman ResourcesNew HopeNoxious WeedProsecuting Attorney's OfficePublic Defenders OfficePublic WorksSheriff's OfficeSuperior CourtTreasurerWSU ExtensionYouth Services
17. Job Title
19. Home address
21. City
22. State
23. Zip Code
25. Email Address
26. Phone Number
28. Date Hired
    Date Hired
29. Time employee beagn work
    Time employee beagn work
31. Location of Incident. (Please be specific)
33. Describe what happened*
35. If an injury, illness, or exposure occurred, what part of the body was affected?
37. Did you go to the Doctor*

    1. Yes
    2. No
39. If yes above, treatment by whom and name of clinic
41. Names of any Witnesses
43. Was the incident/injury caused by a County employee?*

    1. Yes
    2. No
45. How could this have been prevented?
47. Did the incident cause (or have the potential to cause) injury or damage to another employee, member of the public, vehicle, property, or equipment? *

    1. Yes
    2. No

49. *If yes, employee shall complete the "Grant County Risk Management General Liability Loss Notice Form" immediately.

51. Emergency steps taken.
53. Were emergency services contacted?*

    1. Yes
    2. No
55. Was Epinephrine auto-injector used?

    1. Yes
    2. No
57. If yes, who administered?
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59. Submit

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