Teammate Handbook Cover

Were other individuals injured/ill due to this event? No If the object was a mechanical apparatus or vehicle, which part caused the injury? (Such as gear, pulley, motor, etc.) Yes

Did employee receive medical attention?

Yes

No If yes, indicate where medical attention was received:

Was another person responsible for injury? No If yes, who? In circumstances involving motor vehicle accidents, was a police report taken? Yes

Yes

No

Can you recommend ways to prevent the incident from reoccurring?

Name(s) of Witness (es) Was appropriate safety equipment provided?

Was the employee using the mechanical or other safe guards when the incident occurred?

What is the Department doing to prevent such an incident from happening again?

If the employee has restrictions for returning to work, is modified duty available (please explain)?

Supervisor’s Signature: Supervisor Print Name:

Date:

Director’s Signature:

Date:

PLEASE BE SURE TO ADVISE HUMAN RESOURCES WHEN THE INJURED EMPLOYEE IS UNABLE TO WORK OR WHEN THE INJURED EMPLOYEE RETURNS TO WORK

This form must be forwarded to Human Resources within 24 hours of incident to hr @cityofmorganhill.ca.gov.

Revised 10/22