Accident and Incident Reporting Forms Instructions

To submit this form, email all completed documents to per.wcdiv@lacity.org or fax them to (213) 473-3400. For online submissions, please visit the designated city portal. Ensure that physical documents are sent to the appropriate department at 700 E Temple Street, Room 210, Los Angeles, CA 90012.

Keep in mind all relevant submission dates as prescribed by your organization's policies. Accidents should be reported immediately, and relevant forms must be submitted promptly to avoid delays in processing.

The purpose of this form is to accurately document accidents, incidents, and near-misses that occur in the workplace. Completing this form helps an organization to understand the root causes of incidents and prevent future occurrences. It also ensures compliance with regulations set by safety authorities.

• 1. Employee's Report of Injury/Illness Form: This form is to be completed by the injured employee.
• 2. Accident/Incident Witness Statement Form: Used to collect statements from witnesses.
• 3. Supervisor's Investigation Form: Documents the supervisor's findings post-incident.
• 4. Near-Miss Reporting and Investigation Form: Used for cases where no injury occurred, but a potential hazard was noted.

Failing to submit this form can lead to penalties and hinder safety investigations. Compliance with reporting is crucial for organizational safety standards.

• Legal Consequences: Failure to report accidents can result in legal actions against the company.
• Inaccurate Records: Without timely submission, records may become incomplete or inaccurate.
• Increased Risk: Not documenting incidents may lead to unresolved safety hazards.

• 1. Injury Reporting: Essential for documenting any injuries that occur at work.
• 2. Incident Documentation: Used for recording incidents that could potentially result in injury.
• 3. Near-Miss Analysis: Helps in analyzing near misses to prevent future occurrences.