Incident Report - The Arc of East Central Iowa

Employees must report all work-related injuries and accidents immediately to their supervisors in person or by phone. Office: 319-365-0487

This form must be submitted within 72 hours of the incident.

Name *

Gender *

Current Address *

Country

City

State

Zip code

Phone *

Email *

Date of Birth *

Job Title *

Employment Status *

Full Time

Part Time

Marital Status *

Date of Incident *

Time of Incident *

Incident Type *

If Other, please explain:

Part(s) of body directly affected by the injury or illness. (ex: left or right - hand, arm, circulatory system): *

Time Employee Began Work *

Incident on Arc's Premises *

Yes

Where did incident occur? *

Other staff present (list initials)

Was a participant present at time of the incident? *

Yes

Description of Incident *

*For human bites that break the skin - go directly to the Emergency Room of the nearest hospital. No exceptions! * If your injury requires medical treatment, please notify the medical facility that the injury occurred at work.

Immediate Action Taken (select all that apply) *

Resolved by Staff

Treatment by Health Care Professional

Emergency Room Treatment

In-patient Hospitalization

Law Enforcement

Describe the actions taken to treat the illness/injury *

Arc Supervisor *

Supervisor Notified Date *

Arc Supervisor Notified Time *

If seeking medical attention, I authorize the release of:

Medical Records

Social Security Number

Submitted by Name *

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