• Incident Report Form

Medical Incident Reporting

Emergency Dial 911If you are currently experiencing an actual emergency, please dial 911.

Si está experimentando una emergencia actualmente, por favor llame al 911.

Injury/Illness/Exposure Reporting Procedure

All injuries/illnesses must be reported to the Disability Management Unit within 24 hours.  Supervisors and Managers are responsible to complete the Supervisor’s Report of Occupational Injury/Illness/Exposure form and forward it to Disability Management with a copy to their corresponding Department Safety Coordinator and others, according to the Department’s process.  Supervisors must follow the Risk Management report of injury, illness or exposure reporting procedures.

Report a Work-Related Injury Incident to Disability Management

Serious Injury Reporting

Serious injuries as defined in Title 8, Section 330(h) must be reported to Cal-OSHA within 8 hours of notification.  Departments are responsible to provide such notification to the Santa Rosa District Cal-OSHA office with concurrent notice to Risk Management. 

As defined in Section 330(h), a "Serious injury or illness" means any injury or illness occurring in a place of employment or in connection with any employment which requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement, but does not include any injury or illness or death caused by the commission of a Penal Code violation, except the violation of Section 385 of the Penal Code, or an accident on a public street or highway.

Report a Serious Injury to Cal-OSHA

Report a Serious Injury to Risk Management

For further information on reporting requirements follow the link below:

Cal-OSHA Reporting Regulation

Accident/Incident Investigations

Accident/Incident investigations are important tools used to identify safety concerns, determine how an incident could have been prevented and to make recommendations to prevent recurrences.  Departments must follow the Risk Management accident/incident investigation procedures.

Department Safety Coordinators are responsible to review the investigation report for accuracy and completeness.  In addition, the Department Safety Coordinator will collaborate with the Supervisor/Manager in developing recommendations, taking corrective action to prevent future recurrences, and elevating safety concerns to the Department Head.  Accident/Incident Investigations are forwarded to Risk Management within 5 working days for record keeping and program monitoring. 

Injury Data Management

Risk Management is responsible for maintaining information on all reported accidents/incidents through the Workers compensation management database.  Periodic loss reports are generated from this system and forwarded to departments. OSHA 300 logs and OSHA 300a postings are generated from this system and are provided to departments for posting annually, as required by OSHA regulations and upon request.

Return to Report an Incident

Contact Information

Safety Unit
Risk Management Division

Business Hours
Monday – Friday
8:00 AM – 5:00 PM
Address
575 Administration Drive
Room 116 B
Santa Rosa, CA 95403
38.465237, -122.725363

Supervisors Report of Injury Illness Exposure