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2. This form is to be used when reporting any work related accident or a work related injury. A statement from the employee involved will be needed if a claim is filed.
4. First Name of Reporting Party*
5. Last Name of Reporting Party*
7. Date of Incident:*
   Date of Incident:

   Date of Incident:
8. Department:*
   -- Select One --Administrative ServicesDev ServicesFinanceMunicipal CourtPolice Public WorksTown Manager/Town Secretary
9. Type of Incident: *
   -- Select One --Motor Vehicle or Equipment AccidentEmployee Work-Related InjuryMotor Vehicle or Equipment Accident & Employee Work-Related InjuryEmployee Work-Related Incident (No Injury)Act of Nature - Weather RelatedVandalism - Unknown
10. Has Human Resources and Town Secretary's Office been NOTIFIED VIA TEXT/TEAMS/EMAIL/PHONE?*

    1. Yes
    2. No
12. Was Police called out?*
    -- Select One --YesNo
13. Was report ready at time of this submittal?*
    -- Select One --YesNo
14. If Yes, Upload Report:*

    Upload report or draft - final is not needed. 

16. Did Incident Occur during working hours?*
    -- Select One --YesNo
17. Did employee receive medical treatment?*
    -- Select One --YesNoUnknown
18. If Medical Treatment Received, where?*
19. Did employee waive medical treatment?*
    -- Select One --YesNo
21. Did Employee complete Post-Accident Testing?*
    -- Select One --YesNo

    All employees involved in a work related incident/accident are required to complete drug/alcohol testing. 

22. If yes - Is report on file with Human Resources*

    1. Yes
    2. No
    3. Unknown
23. Where was Post Accident Testing Conducted?*
24. Upload Post/Accident Results if you have them available.

    If this document is not available - please submit via the Supplemental Incident Report Form as soon as it is received. 

26. Was the damage to Town Property over $500?*
    -- Select One --YesNo
27. Does a claim need to be started for Repairs?*
    -- Select One --YesNo
29. REMINDER: If drug/alcohol screening results are not uploaded as part of this report, please ensure it is provided directly to Human Resources for filing in Employee File.
31. First Name of Employee Involved:*

    If  not employee related - list  "None"

32. Last Name of Employee Involved:*

    If  not employee related - list  "None"

34. Department:*
    -- Select One --Administrative ServicesDevelopment ServicesFinanceMunicipal CourtPolice DepartmentPublic WorksTown Secretary's OfficeTown Manager's Office
35. Title of Employee:*

    If  not employee related - list  "None"

36. Employee Phone:*

    If  not employee related - list  "None"

38. Location of Address Where Incident Occured:*
40. City*
41. State*
42. Zip Code*
44. Equipment/Vehicle ID:*

    If no vehicle/equipment involved - list "None"

45. VIN:*

    If no vehicle/equipment involved - list "None"

47. Provide details of the Incident/Injury:*
49. List Witnesses (other employees present):*

    If None - Write N/A

51. Please list if there were other parties involved who are not employees.
53. Were other parties involved?*
    -- Select One --YesNo
54. How many other parties were involved?*
    -- Select One --1234 or More
56. Name
57. Email Address
59. Address
61. City
62. State
63. Zip Code
65. Phone Number
67. Name
68. Email Address
70. Address
72. City
73. State
74. Zip Code
76. Phone Number
78. If more than 2 please enter information below:*

    Party Involved, Home Address, Email Address and Phone 

    
    

80. If documents are not available at the time of initial submittal, please use link below to submit when received.
    Supplemental Incident/Accident Reporting Form
82. Image and Picture Upload

    You can upload multiple files at once, with the size limit being 20MB.   Anything larger can be reduced in size via PDF and uploaded.

84. Image/File Upload:
85. Image/File Upload:
86. Image/File Upload:
87. Image/File Upload:
89. Image/File Upload:
90. Image/FileUpload:
91. Image/File Upload:
92. Image/File Upload:
94. Image/File Upload:
95. Image/File Upload:
96. Image/File Upload:
97. Image/File Upload:
99. Image/File Upload:
100. Image/File Upload:
101. Image/File Upload:
102. Image/File Upload:
104. Image/File Upload:
105. Image/File Upload:
106. Image/File Upload:
107. Image/File Upload:
Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field