Employee Accident/Incident Report
NeighborImpact Human Resources & NeighborImpact Safety Committee
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Form Filler Name
*
First Name
Last Name
Current Date
*
-
Month
-
Day
Year
Date
Report Type
*
Employee
Volunteer
Other
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Incident Details
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Employee Involved:
*
First Name
Last Name
Person Involved:
*
First Name
Last Name
Volunteer Involved:
*
First Name
Last Name
Title
*
Department:
*
Please Select
Child Care Resources
Communications
Community Development
Development
Early Head Start
Energy Assistance
Executive
Facilities
Finance
Food Program
Head Start
HomeSource
Housing Stabilization
Human Resources
Information Technology
Lending
Representative Payee
Special Projects
Supportive Services
Weatherization
Supervisor's Email Address
Ask if you do not know it!
Location injury occurred at:
*
Please Select
Becky Johnson HS Site
Bend Empire NeighborImpact Office
Bend Weatherization Office
Child Care Resources Downtown
Child Care Resources Eagle Crest
East Bend HS Site
Empire EHS Site
Healy Heights HS Site
Juniper EHS Site
La Pine Coach Road HS Site
La Pine Early HS Site
La Pine Finely Butte HS Site
La Pine JCJ HS Site
La Pine NeighborImpact Office
Lynch Elementary HS Site
Madras NeighborImpact Office
Nancy's House Family Shelter
Ochoco HS Site
Prineville Early HS Site
Prineville HS Site
Prineville NeighborImpact Office
Redmond Early HS Site
Redmond Main Office
South Bend HS Site
Stepping Stone Shelter
Vern Patrick HS Site
Walker EHS Site
Walker HS Site
Westside HS Site
Specific location of incident
*
Playground, bathroom, parking lot, employee's office, lobby, etc
Date and Time of Event
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Were others involved or were there witnesses?
*
Yes
No
Who else was involved?
*
What happened? Describe incident in detail. Include activity, where, how, equipment or objects involved, witnesses, who was supervising, etc.
*
Description of Injury, Extent, and Body-Part Involved
*
What was done for the injured person?
*
First Aid Administered?
*
Yes
No
By whom?
*
First Name
Last Name
911 Called?
*
Yes
No
Physician/Hospitalization Required?
*
Yes
No
Name of Physician
*
First Name
Last Name
Name of Hospital/Clinic
*
Potential Bloodborne Pathogen Exposure?
*
Yes
No
Were Universal Precautions Used?
*
Yes
No
Who else was exposed?
*
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Incident Causes and Remedies
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What factors contributed to this accident/incident?
*
What actions are being taken/should be taken to prevent reoccurrence?
*
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