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Safety Incident Notifications

  1. Safety Incident Notification Form

    Please complete this form for any near-miss or incidents.

  2. Contact Information

  3. Report All Injuries

    If you have an injury, report it using the Company Nurse Injury Hotline at 1-888-770-0928

  4. Did an injury occur?

  5. Property or Equipment Damage

    If Urbandale or private property or equipment was damaged, notify your supervisor immediately.

  6. Was Property or Equipment Damaged?

  7. Contributing Factors

  8. Please provide specific factors and examples

  9. Future Outcome

  10. What could have been the result?

  11. Prevention

  12. Once submitted the information will be forwarded to the City's Safety/Wellness Task Force for review.

    A copy of this form, along with any follow-up recommendations will be sent to your Department Director. If necessary, the Safety Incident Prevention Team may contact you or your supervisor to gather more information as part of their on-going effort to make Urbandale a safer place to work.

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