Risk Management Reporting Forms

Work-Related Injuries

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. 

Individual Work-Related Injury Forms for Print 

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.

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
  • Amputation
  • Fatality

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 

Hazardous & Non-Hazardous Spill Reporting Form (PDF) - Updated 12-2021

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 

Near Miss Reporting Form (PDF) 

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 

Utility Strike Reporting Form (PDF)

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

Vehicle Accident Reporting (PDF)

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
  • Stop
  • 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 

Witness Statement Form (PDF)

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:

Risk Management
 
Monday – Friday 
 8:00am to 4:30pm
757-727-6617