Employee'S Incident Report - Montgomery County Schools - 2013
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1REPORT ONLY
EMPLOYEE’S INCIDENT REPORT
INCIDENT DATA
(Please Print)
Date of incident: _____/_____/_____
Date requested medical attention: _____/_____/_____
Time of Incident: _______ am/pm (circle)
Where did it happen? _______________________________________
What equipment or chemicals were you using when this happened? ________________________________________
What work process were you performing? (i.e., food service, custodial, teacher, teacher aide, transportation,
maintenance, etc.) _________________________________________________________________________
What were you doing specifically when the injury/illness occurred? (i.e., lifting, walking, running, driving, etc.)
_______________________________________________________________________________________________
Did you receive training on how to properly perform the work you were doing? Yes_________ No________
Did you receive training on how to avoid injuries while performing this work?
Yes_________ No________
Who conducted this training?_______________________________ When?___________________________
Describe in detail the sequence of events and include objects, equipment or people that directly caused your injury:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ο Yes ο No
Did you report this injury/illness to your Supervisor?
If yes, date: __________
If no, why not? __________________________________________________________________________________
Give name(s) of witness(es) to your injury/illness: ______________________________________________________
Could this injury have been prevented? How?
_______________________________________________________________________________________________
What part(s) of your body were hurt?
(Mark the appropriate blank or write in R for Right, L for Left when applicable.)
Head:
___Face
___Skull
___Neck
___Mouth
___Nose
___Eye
___Ear
Trunk: ___Chest
___Shoulder
___Upper back ___Lower back
___Abdomen
___Hip
Arm:
___Upper ___Elbow ___Wrist ___Hand ___Palm
___Finger
Leg:
___Foot
___Knee ___Thigh ___Ankle
___Calf
___Toe
Other: ____________________________________________________________
What type of injury/illness do you have? (Check all that apply)
ο Abrasion (scrape)
ο Strain/Sprain
ο Bruise
ο Poisoning (Ivy, Oak, Other)
ο Fracture
ο Cut/Puncture
ο Crush
ο Burn
ο Respiratory
ο Amputation
ο Swelling
ο Dislocation
ο Other: ____________________________________________________________
Please circle the injured or affected area on the right.
All the information I have provided in this report is true and correct. I understand that providing false or
misleading information or omission of information on this report or any other form related to this injury may
result in termination of my employment.
Employee Signature: ____________________________ Date: _____________ Witness:______________________
Montgomery County Schools
1
10/11/2013
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