KLAMATH COUNTY HUMAN RESOURCES - RISK MANAGEMENT
INCIDENT & ACCIDENT REPORT FORM
Please use the Injury Report Form (KCHR Form #8) to report employee injuries.
Department: ______________________________________ Date & Time of Incident: __________________________________
Name, Address & Phone Number of the Persons(s) Involved:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please indicate whether each person listed above is a: Guest, Visitor, Vendor, Prisoner, Employee, Volunteer, etc.
Describe What Happened: ________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Where did the incident occur (please describe the specific location):________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Describe any damage to property___________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
o
County-owned propertyo
Property owned by others, please detail____________________________________________________________________Describe any injuries______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
o
Injury to County employee (be sure to complete the Injury Report Form, KCHR Form #8)o
Injury to others, please detail______________________________________________________________________________
Were there any witnesses? (Please provide names, addresses and phone numbers):
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
AUTO ACCIDENT OR CLAIM
Vehicle Year, Make & Model ______________________________ State & License Plate # ____________________________
o County-owned vehicle o Private owner
Vehicle Year, Make & Model ______________________________ State & License Plate # ____________________________
o County-owned vehicle o Private owner
Private Owner’s Name & Address ___________________________________________________________________________
Insurance Company _______________________________________________________________________________________
Is the vehicle still operable? _________________ Where is the vehicle now? _______________________________________
Was a Police Agency Contacted?____________________________________________________________________________
Other Information or Action Taken: ___________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
For more information on this situation, please contact:
Name___________________________________________________________ Phone Number __________________________
_________________________________________ ____________________________ _______________
Reporting Staff Member Phone Number Date
_________________________________________ ____________________________ _______________
Department Head Phone Number Date