Revised 29 Mar 2010

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 Chris Mullinax/
Risk Mgmt on her cell phone. Take photos whenever possible.

Chris/Risk Mgmt:

Office: (520) 432-9720

Cell: (520) 234-4613

Fax: (520) 432-9716 


I. Incident
II. Citizen Information
III. Incident and Injury Description
IV. First Aid
V. Transport
VI. Statement(s)
VII. Report