Citizen Mishap/Injury Form

County employee: Complete this form at the time and site of the injury and send it immediately to Risk Management. If the citizen requires medical care, also call Risk Mgmt. Take photos whenever possible.

Risk Mgmt: Office: (520) 432-9720
Fax: (520) 432-9716
Email: jmorales@cochise.az.gov

I. Incident

Date *

Time *

Department

City of Incident *

Specified Location *

II. Citizen Information

Name *

Date of Birth *

Mailing Address *

City *

Zip *

III. Incident and Injury Description

Body part(s) and type(s) of injury (i.e., bruises on front and outside of right knee): *

What was the citizen doing at the time of the injury? *

How did the incident/injury occur? *

How could the injury have been prevented? *

IV. First Aid

First Aid *

Accepted

Declined

Not Needed

1st aid given by - name

Comments

V. Transport

Time citizen departed County facility

Means of Transportation

Own Vehicle

Other Vehicle

Ambulance

If Ambulance Was Used, Please List Name

Destination

Home

Hospital

Other...

Destination Other...

If Transported to Hospital, Which One?

VI. Statement(s)

Injured citizen's description of incident *

Citizen's printed name *

Witness description of incident

Witness printed name

Witness home/cell phone

Witness relation to citizen

VII. Report

Completed by *

Reviewed by *

Leave this field blank

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Citizen Mishap/Injury Form

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