Risk Management Reporting Forms
Employees must report work-related injuries immediately to their supervisor. Failure to do so could jeopardize their benefits.
For more information on the City of Hampton’s Workers’ Compensation Program please visit the Personnel Policies Manual and Instructions PAI 6.2 Workers’ Compensation.
- Supervisor’s Guide to Handling a Work-Related Injury- PLEASE READ BEFORE PRINTING FORMS (PDF)
- Supervisor's Full Packet for Reporting Work-Related Injuries (PDF) - Updated 12-2021
Individual Work-Related Injury Forms for Print
- First Report of Work-Related Injury (EIR 1000) (PDF) - Updated 12-2021
- Important Facts about Workers Compensation (PDF) – Updated 12-2021
- Physicians Medical Report (PDF)
- Prescription Coverage Form (PDF)
Medical Appointments due to a Work-Related Injury (inclusive of physical therapy, etc.)
Please read the information found in the Employee Instructions for Handling Work-Related Medical Appointments carefully. This instruction applies to leave requests for appointments during working hours.
- Employee Instructions for Handling Work-Related Medical Appointments (PDF)
- Time Tracker for Work-Related Medical Appointments- Single form for Print (PDF)
Reporting an Emergency
All City of Hampton departments and divisions, you must report to Risk Management immediately if an employee sustains an injury that is any of the following:
- Patient transport by ambulance
- In-patient hospitalization
- Loss of eye
Please contact the Department of Risk Management immediately at the Emergency Numbers shown below:
Emergency Contact (first call)
Risk Manager 757-870-3472
Emergency Contact (second call- if unable to reach first call contact)
Claims Manager 757-810-8673
Emergency Contact (third call if first two cannot be reached)
Occupational Health & Safety Coordinator 757-268-7449
For Public Works Emergencies, please also call:
Public Works Safety Coordinator 757-759-6973
Incident Reporting Forms
Reporting forms below are the most current. Please make sure to only use the most revised version of the reporting form. All forms previous should be discarded.
Hazardous & Non-Hazardous Spill Reporting
In the event of a hazardous spill, the instruction provided below applies to all employees:
- Contact 911 immediately for hazardous spills of 5 gallons or more.
- Contact 911 if any material of any quantity (known or unknown) enters into a storm drain, drainage ditch or any type of waterway.
- Contact your supervisor- your supervisor is trained on who to contact next.
Hazardous material spills of 25 gallons or more must be reported to the National Response Center (NRC) 1-800-424-8802. In the event of a hazardous spill emergency, please follow all reporting instructions provided by your department and Risk Management.
Citizen, Participant, Volunteer, & Visitor Incident Reporting:
Citizen, Participant, Volunteer, & Visitor Incident Reporting Form (PDF) - This form should be used to report injuries involving citizens, participants, volunteers, and contractors.
Near Miss Reporting
This form is used to track near misses. A near miss is an event that occurred but did not cause property damage or injury. These events are equally important to document as they help to prevent future larger occurrences.
Property Damage Reporting
Property Damage Reporting (PDF) - This form should be used for all damage incurred to city, citizen, or vendor property.
Utility Strike Reporting
This form should be used for all damage to utilities. In the event of a utility strike that could be one of gas or electric, please contact 911 immediately and move to a safe area. Please follow all reporting instructions provided by your department and Risk Management.
Vehicle Accident Reporting
This form should be used to report vehicle accidents and incidents. In the event you are in an accident/incident while driving a city vehicle:
- Remain calm
- Remain at the scene, if it is safe;
- If you are on a busy street, intersection, or dark area, move to a safer location nearby.
- Call 911
- Contact your supervisor
For accidents involving injury, please contact 911 immediately and follow all reporting instructions provided by your department and Risk Management.
Witness Statement Form
This form is used to obtain additional information from witnesses. Please ensure this form is sent to Risk Management along with the corresponding reporting form.
For any questions or concerns about reporting or information located on this website, please contact Risk Management during business hours:
Monday – Friday
8:00am to 4:30pm