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City of Kalispell Supervisor’s Follow-up Injury/Illness &/or Incident report Date & Time of Injury/Incident: Department(s) Involved: Date reviewed by Supervisor: Employee(s) Involved (If applicable): 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