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Non-Injury Incident Report Form
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This form has been modified since it was saved. Please review all fields before submitting.
Form Instructions
Use this form to file reports to the City's Safety & Risk Management Division for the following types of incidents: property damage to City property, graffiti, City tree falling down and damaging property, reports of uneven sidewalks, potholes, other public safety hazards, etc.
Type of Claim
*
City Property Damaged
Graffiti
City Tree Caused Property Damage
Sidewalk Trip Hazard
Pothole
Vehicle Accident
Lost Property
Other (explain below)
Time & Date of Loss
*
Time & Date of Loss
Time & Date of Loss
Location of Incident
*
Description of Incident
*
Please provide a thorough description of the incident. Written witness statements, police reports, photos and other supporting documents can be attached below
Responding Police Department
*
Rockville City
Montgomery County
Other
No Police Responded
Police Report Number
Additional Information
Witness Statement
Police Report
Photo
Photo
Photo
Photo
Photo
Photo
Quote or Invoice
Quote or Invoice
Your Name (First & Last)
*
Your Email Address
*
Your Phone Number or Extension
*
Your Department
-- Select One --
City Attorney
City Clerk
City Manager
Community Planning & Development Services
Finance
Human Resources
Information Technology
Police
Public Works
Recreation & Parks
Has the Unsafe Condition been Addressed?
Yes
No
N/A
Please answer the questions below if this was a vehicle accident involving a City vehicle.
City Vehicle Number
Was Driver or Passenger Injured?
Yes
No
Description of Damage to City Vehicle
Was City Vehicle Towed?
Yes
No
Name and Contact Information for Other Driver Involved
You are required to submit to post-accident drug and alcohol testing if you were driving a City vehicle and involved in an accident, regardless of fault, and damage occurred to either the City vehicle, other vehicle involved or property damage of any kind. Please immediately contact the Human Resources Department at 240-314-8470 to schedule an appointment with Concentra to perform this testing. You are not authorized to operate City vehicles or equipment until the Safety & Risk Manager provides written authorization regarding your negative test results. This policy excludes the Police Department. The Police Department follow General Order policy 4-6.
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