First Report of Incident Injury

Employee must return a completed Incident Injury Report Packet to Custodial Services Admin. The packet has three pages. The incident report - FRI - (first page) must be completed by the employee. The confirmation and consent (second page) must be signed by both the employee and supervisor. The Acknowledgement Form - AF - (third page) must be completed and signed by the employee. Failure to complete the packet in its entirety will cause a delay in processing and must be returned to the employee for corrections. 

(Images link to Incident Report Packet)

Contacts

First Report of Incident Injury Memo and Acknowledgment Form must be submitted to the following individuals by email:

TO:

1. Training Manager (Currently: Elizabeth Saavedra)
2. Senior HR Support Specialist (Currently: Wendy Whipple)

CC:

1. HRSS Department Email
2. Senior Employee Relations Specialist (Currently: Annette Williams)
3. Night or Day Shift Manager (Night - Andy Yanez, Day - Seyfi Yazicioglu)

Email Sample

Email sent to HR with First Report of Incident Injury Memo and Acknowledgement Form

• Subject: First Report of Incident Injury Memo and Network Acknowledgement Form for (employee name) – (Date of Injury 00/00/0000)