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Supervisor First Report of Injury

  1. This form is required to be submitted to report all work-related injuries sustained to employees, volunteers or patrons. This form is also used to report injuries sustained to visitors on City property. This form is required to be completed by the end of the business day in which the incident occurs. Serious injuries must be reported immediately to the Safety & Risk Division by calling Loss Control Specialist Jason Weintraub (x8475 or cell: 724-877-4187) or Safety & Risk Manager Marcus Odorizzi (x8467 or cell: 570-898-3061). Serious injuries are considered any treatment requiring in-patient hospitalization, amputation, loss of an eye or fatality.

  2. Or Name of Injured Patron/Volunteer

  3. Enter the actual phone number where we can reach the injured employee and not a generic City number.

  4. Include name, address and phone number so we can accurately submit bills for payment.

  5. Attach witness statements, accident investigation notes or any other pertinent information related to this claim.

  6. Attach witness statements, accident investigation notes or any other pertinent information related to this claim.

  7. Upon completing the form, a representative from the City's Safety & Risk Management Division will call or email you to obtain additional information regarding your responses, if applicable. Please contact Jason Weintraub at jweintraub@rockvillemd.gov or x8475 with questions regarding how to enter the injured employee's time into Kronos.

    I hereby affirm the information provided is accurate to the best of my knowledge. I acknowledge the City's Safety & Risk Manager, or designee, has the authority to verify the validity of the answers provided in this report.

  8. Leave This Blank:

  9. This field is not part of the form submission.