City of Corvallis Internal Incident Report

Type of Incident *

City Property/Auto Damage

Property/Auto Damage to Others

Injury to Others

Stolen Property

This internal form is for City employee use ONLY to report damage to property, auto damage, injuries to non-City employees, or stolen property. This form is not used to report employee injuries or to file a complaint about City employee behavior. The complaint form for employee behavior may be found here.

If any of the above checked incident types occur, please fill out this form as much as applicable and submit within 24 working hours to the City’s Risk Manager and your Department Supervisor. The purpose of this form is for an incident or claim to be handled and tracked appropriately.

Employee's Name *

Department *

Phone *

Supervisors Email *

Date of Incident * +

Time *

AM/PM *

am

pm

Location of Incident *

Description of Incident *

0/2000 characters

If internal vehicle involved

Vehicle Make and Model (internal)

Year

License Plate #

If outside vehicle involved

Vehicle Make and Model (outside)

Year

License Plate #

Upload additional items if needed: photos, documents, etc. (10MB Max.)

If we have the external Individual(s) information for either who caused damage or who the City caused damage to, please enter below:

Last Name

First Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Witnesses

Name (Witness 1)

Address

Phone Number

Name (Witness 2)

Address

Phone Number

Employee Signature *

clear

Date * +

* Required Items