This form is required to be submitted to report all work-related injuries sustained to employees. This form is required to be completed by the end of the business day in which the incident occurs. Serious injuries must be reported immediately to the Safety & Risk Division by calling Jamie Kohler, Safety Specialist, at x8475 or Marcus Odorizzi, Safety & Risk Manager, at x8467. Serious injuries are considered any treatment requiring in-patient hospitalization, amputation, loss of an eye or fatality.
Enter the actual phone number where we can reach the injured employee and not a generic City number.
Include name, address and phone number so we can accurately submit bills for payment.
Upon completing the form, a representative from the City's Safety & Risk Management Division will call or email you to discuss your injury, treatment, claim and return to work status.
I hereby affirm the information provided is accurate to the best of my knowledge and agree to comply with the requirements of the City's Job-Injury Leave policy which is contained in the Personnel Policies and Procedures manual. I acknowledge the City's Safety & Risk Manager, or designee, has the authority to verify the validity of the answers provided in this report.
This field is not part of the form submission.
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