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Safety Incident Notifications

2. Safety Incident Notification Form
   Please complete this form for any near-miss or incidents.

   Please complete this form for any near-miss or incidents.

3. Today's Date
   Today's Date

   Today's Date

4. Location of Incident

6. Description of Incident or Near-Miss Event

8. Contact Information

10. First Name

11. Last Name

13. Department

15. Supervisor

17. Phone Number

18. Email Address

20. Report All Injuries
    If you have an injury, report it using the Company Nurse Injury Hotline at 1-888-770-0928

    If you have an injury, report it using the Company Nurse Injury Hotline at 1-888-770-0928

21. Did an injury occur?

    1. Yes
    2. No

23. Briefly Describe the Extent of the Injury:

25. Property or Equipment Damage
    If Urbandale or private property or equipment was damaged, notify your supervisor immediately.

    If Urbandale or private property or equipment was damaged, notify your supervisor immediately.

26. Was Property or Equipment Damaged?

    1. Yes
    2. No

28. Briefly Describe the Damage:

30. Contributing Factors

31. What factors do you feel contributed to the incident or its severity?

    Please provide specific factors and examples

33. Future Outcome

34. What was the potential risk of the incident or near-miss?

    What could have been the result?

36. Prevention

37. What actions could have been taken to prevent this incident or near-miss?

39. Once submitted the information will be forwarded to the City's Safety/Wellness Task Force for review.
    A copy of this form, along with any follow-up recommendations will be sent to your Department Director. If necessary, the Safety Incident Prevention Team may contact you or your supervisor to gather more information as part of their on-going effort to make Urbandale a safer place to work.

    A copy of this form, along with any follow-up recommendations will be sent to your Department Director. If necessary, the Safety Incident Prevention Team may contact you or your supervisor to gather more information as part of their on-going effort to make Urbandale a safer place to work.

41. H.R. Notes

    Please add notes on this notice.

Leave This Blank:


43. Submit

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