• Employee Report of Incident/Accident

    Completed by DPI Employee
    • This form is to be completed in your words, to the best of your recollection.
    • Please be as detailed as possible.
    • If other people were involved or witnessed the incident, please take their names/contact info, and/or send them this link to the witness form: https://dpi.jotform.com/231085601599157
    • Attach any documentation and/or photos via the upload button below. You will be contacted if there are additional questions or more information is required.
  • Date*
     - -
  • This is a report of (check all that apply):*
  • Date the incident/accident occurred:*
     - -
  • Were you physically hurt in any way?*
  • Do you get medical attention/treatment?*
  • Hospital/Clinic Info*
  • Did you leave work before your shift was over?*
  • Did you miss any full days of work?*
  • Date you returned to work:*
     - -
  • Time of incident/accident:*
  • Were you driving a DPI Fleet Vehicle?*
  • Was there another vehicle involved?*
  • Was the other driver 'at fault' or 'equally' at fault?*
  • Format: (000) 000-0000.
  • Take photo of proof of insurance of other driver: *

  • Please take photos all around the other vehicle if possible (to document condition post-accident).

  • Take Photo
  • Were there any witnesses to the incident?*
  • Witnesses*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • My signature below indicates that this is a truthful representation of the facts surrounding this incident. I also acknowledge that should it become apparent (through investigation, legal procedings, or other mechanisms) that I have misrepresented the facts, I will be subject to disciplinary action up to and including termination. 

     

  • Should be Empty: