City of Duluth Incident/Injury Report
Supervisor to complete within 24 hours of incident/injury. If injury required treatment by a medical provider, attach medical
documentation. Completed forms should be emailed to firstname.lastname@example.org.
Date of incident/injury: Employee Non-Employee Department/Division:
Choose one that best describes this claim: Incident only, no medical care Medical only, no lost time Injury includes lost time
Initial treatment sought: Hospital ER
Refused to see MD / None
Doctor/clinic name, address, phone number:
First name: MI: SSN:
City: State: Zip code: Phone: Date of birth:
Date of hire: Occupation: Gender: Male Female
Did accident, injury, or incident occur on employer's
premises? Yes No
Name and address of the place of the occurrence:
Time employee began work: a.m. p.m. Time of accident, injury, or incident: a.m. p.m.
Date employer notified of accident, injury, or incident: Date employer notified of lost time:
First date of any lost time: Return to work date: RTW with restrictions: Yes No N/A
Describe the nature of the accident, injury, or incident. Be specific. Include body parts affected.
Describe the activities when the accident, injury, or incident occurred with details of how it happened.
What tools, equipment, machines, objects and/or substances were involved?
Incident investigation conducted: Yes No Date supervisor notified: Date report completed:
Supervisor name: Supervisor phone number:
Names and phone numbers of witnesses:
Incident was a result of: safety violation machine malfunction product defect motor vehicle accident N/A
What actions have been taken to prevent recurrence?