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City of Kalispell INCIDENT REPORT Human Resource’s Phone: [PHONE REDACTED] Fax: 758-7847 ● Note: Injured employees 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 are to be investigated by a law enforcement agency immediately. PLEASE PRINT! Employee Filing Report: Payroll Department(s) Involved: Date & Time of Report: Accident: Theft: Vandalism: Other: Employee’s Supervisor: Date & Time of Incident: Date & Time Supervisor Notified: Weather Conditions: Specific Location / Address: Description of incident: Was there damage to City property? Yes No Was there damage to private property &/or injury to a private citizen? Yes No If yes to either question, did law enforcement investigate? Yes No If applicable, Officers Name: Case Report Number: INFORMATION FOR INJURY AND/OR PROPERTY DAMAGE Describe injuries &/or damage to property &/or equipment ( if applicable include: License VIN, Year, Make, Model) Estimated Property Damage Amount: If Applicable, Legal Owner’s Name of Damaged Property and/or Name of Injured Party and their mailing address: Telephone Numbers: Home: Work: Cell: Witness 1: (Include name, address and phone) Witness 2: (Include name, address and phone) Signature of employee filing report Date NOTE: ONCE COMPLETED FORWARD ORIGINAL TO HUMAN RESOURCES IMMEDIATELY! Revised 9/10/2012 S:\Forms\Incident Report Form SIGN ---PAGE BREAK--- City of Kalispell Supervisor’s Follow-up Injury/Illness &/or Incident report Date & Time of Injury/Incident: Department(s) Involved: Date reviewed by Supervisor: Brief Description of Incident: Supervisor’s Comments, Corrective Actions & Signature Signature of Supervisor Department Head’s Comments & Signature: Signature of Director/Chief Additional Comments: NOTE: ONCE COMPLETED, FORWARD ORIGINAL TO HUMAN RESOURCES ALONG WITH ANY SUPPORTING DOCUMENTATION SIGN SIGN