05/07/10 Incident Report4
City of Kalispell
P.O. Box 1997 Kalispell, MT 59903-1997 Phone: (406) 758-7757 Fax: 758-7758
INCIDENT REPORT
• Employees injured use: "Employees Report of Job Related Injury / Illness" Form.
• All collisions that result in personal injury or damage involving City vehicles or persons on duty and actively
engaged in City business will be investigated by a law enforcement agency immediately.
PLEASE PRINT!
Em
oyee Filing Re rt:
Payroll #:
Deptment(s) Involved:
port:
Date Ti e of Reap
Accident: Theft: Vandalism:
Other:
Employee's Supervisor:
Date Timq of Incident:
/7 2oi o
7Date
& Time Suppervisor Notified:
Weather Co?ditipn,4
Specific Location / dress:
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Desiption o inci eot:
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Was there damage to City property? Yes No
Was there damage to &/or injury to a citizen? Yes No
private property private
If to either did law enforcement investigate? Yes No
yes question,
If applicable, Officers Name:
Report Number:
INFORMATION FOR INJURY AND/OR PROPERTY DAMAGE
Describe injuri'e,p &/or damage to property i0/or equipment (if applicable include: [Acense #, VIN, Year, Bake, Model)„
Estimated Property Damage Amount:a�.'
If Applicable—, Legal Owner's Name of Damaged Property and/or Name of Injured Party:
S �d -C�tPo
Mailing Address:
Telephone Numbers: Home: Work: Cell:
Witness 1: (Include name, address and phone)
Witness 2: (Include name, address and phone)
nature o eFT111loyee filing rEport Date
NOTE: ON E COMPLETED FORWARD ORIGINAL TO HUMAN RESOURCES IMI
Revised 8/17/2005 S:\Forms\Incident Report Form
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Supervisor's Comments, Corrective Actions & Signature
Department Head's Comments &Signature:
Additional Comments:
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NOTE: ONCE COMPLETED, FORWARD ORIGINAL TO HUMAN RESOURCES ALONG WITH ANY SUPPORTING DOCUMENTATION