Incident Report

INCIDENT REPORT: NON-EMPLOYEE (see Page 3 for instructions)

DATE OF INCIDENT: TIME OF INCIDENT: INJURED PARTY Name: Address: Telephone Number:

Description of Injuries: Did the Injured Party seek medical attention? Yes No How did It Happen?

PROPERTY DAMAGE Owner’s name: Address: Telephone Number:

Extent of Damage: How did it Happen?

PLEASE CONTINUE ON FOLLOWING PAGE

PSD-RM 301 (Revised 7/19/06) File Original with Risk Management INCIDENT REPORT: NON-EMPLOYEE (see Page 3 for instructions)

PLACE OF INCIDENT Location: Owner of Premises/Equipment: Address: Telephone Number:

Were Repairs or Alterations in Progress? Yes No If Yes, describe:

WITNESSES Name Address and Telephone Number 1. 1. 2. 2. 3. 3. SIGNATURE (Please sign, or check box and type in Name ONLY IF submitting via e-mail, and fill in the rest of the information below before submitting.)

Employee Signature Date of Report

Employee Title Department and Telephone Number

PSD-RM 301 (Revised 7/19/06) File Original with Risk Management INCIDENT REPORTING PROCEDURE

1. This form must be used by all departments to report the following types of incidents:

A. Any accident or incident (other than a motor vehicle accident) where there is ANY TYPE OF COUNTY INVOLVEMENT and wherein any person not employed by the County has sustained death or bodily injury.

B. Any accident or incident (other than a motor vehicle accident) in which the County is in any manner involved, and where there is resultant damage to property not owned by the County of Fresno.

2. A County employee having knowledge of the accident or incident should complete the applicable areas of this form. The original should be forwarded to the Risk Management Division of the Personnel Services Department as soon as possible after the accident or incident has occurred. The originating department should keep a copy of the completed form.

A hard copy of this form may be submitted to Risk Management, Stop #188. E-copies may be sent via e-mail to Tracy Meador at [email protected].

3. Blank forms may be obtained from Risk Management by calling 488.3360.

PSD-RM 301 (Revised 7/19/06) File Original with Risk Management