DPI Accident/Incident Report Form

Incident/Accident Report

Completed by DPI Supervisor
This form is to be completed by the DPI Supervisor. The report that the employee needs to complete can be found here (or on the employee website safety page).

Each state has specific procedures due to the different insurance carriers:

Arizona

Arkansas

Idaho

Maryland

Minnesota

Oregon

Pennsylvania

Washington
Date*

MonthDayYear
Department*
State*
This is a report of a:*

AccidentMinor Injury (cuts and scrapes)AssaultDisease/ExposureChemical/InhalationCar AccidentVerbal Assault/ConflictProperty Theft/DistructionDeathOther
Employee Name*

First NameLast Name
Employee Job Title*
Report completed by*

First NameLast Name
Email address (of person completing the form)*
example@thedpigroup.com
Email address of your supervisor (or anyone else that should receive a copy of this report)*
example@example.com
Date of incident/accident*

MonthDayYear
Time of incident/accident*

:HourMinutesAM/PM Option
Location incident/accident occurred*
Description of incident/accident*
Did the employee miss any days of work following the incident?

YesNo
If 'yes' to above question, have they returned?
What part of the body was injured (if there was an injury)?
Did employee go to the doctor or hospital?*
Were police involved?*
During what part of employee's workday did incident occur?*
Describe the location/environment at the time of the incident/injury:*
Where did it occur, what was the weather like if that was a contributing factor, was it messy, hot, icy, noisy, etc.
How could this incident be avoided in the future? (Safety changes, coaching, etc.)*
Witnesses
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Incident/Accident Report