Incident and Accident/Injury/Illness Forms and Instructions
- Click here to access an Accident/Injury/Illness Report
- Email the completed report to: email@example.com
- If the incident involves a facility issue, a copy of the incident report must also be emailed to: firstname.lastname@example.org (Dennis Palmer)
- A copy of all incident reports involving a local office (only) must also be emailed to: email@example.com (Janet Garcia Hobbs)
- Forward a copy of the completed report to your supervisor.
BODILY INJURY AND/OR PROPERTY DAMAGE:
If a DWD staff member is injured, State form #34401 must be completed and submitted to HR immediately. This form is available at https://forms.in.gov/Download.aspx?id=4916.
Any person claiming injury or property damage, either on DWD property or by a vehicle owned and operated by DWD, and who indicates a desire to be compensated for the loss, should obtain a copy of “Claim for Personal Injury or Property Damage” form to complete and mail as instructed. See DWD Policy 2011-03.
The aforementioned reports and forms must be completed wholly and to the best of the individuals’ knowledge. The summary must be specific, clear and concise. In order to preserve the integrity of the information available, the preparer should complete the form immediately upon becoming aware of the circumstances to be reported but no later than 24 hours after the incident occurs.
QUESTIONS OR ASSISTANCE:
Contact the Investigations/Security Section of DWD at 317-234-3094.