Injury Report Form Name of Member Involved (required) Email (required) Date/Time of Incident (required) Regular Assigned Work Group or Shift (required)A Shift B Shift C Shift Reserves IFT Wildfire Administration Type of Incident (required)EMS Exposure Injury Reporting or Emergency Treatment (required)No Treatment - Reporting Only Urgent Care - Occupational Med Required Emergency Room Location of Incident (required)DFR Facility/Property Emergency Incident Off-Site Location Non-Emergency Scene Off-Site Location Describe the Event [be specific with part(s) of body (i.e. left index finger, right knee, lower back, etc.) and with what type of injury (i.e. bruised, sharp pain, hurts when I walk, throbbing, etc.)] (required) Witness 1 - Name Witness 1 - Phone Witness 2 - Name Witness 2 - Phone There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
