Risk Management Forms

***Dear Injured Worker***

Please do not print Workers' Compensation forms off the website unless instructed by your supervisor to do so. You must report the injury through your supervisor. Failure to do so could jeopardize your benefits.

You can also contact Risk Management for a Quick Reference Guide at 757-727-6617.

• Supervisor's Full Packet for Reporting Work-Related Injuries (PDF)
  • First Report of Work-Related Injury (EIR 1000) (PDF)
  • Important Facts About Workers Compensation (PDF)
  • Physicians Medical Report (PDF)
  • Prescription Coverage Form (PDF)

For all city of Hampton and Hampton City Schools departments and divisions, if an employee sustains an injury that is any of the following:

• Patient transport by ambulance,
• In-patient hospitalization,
• Loss of eye,
• Amputation,
• Fatality,

You must report the mishap immediately using the following emergency numbers:

Risk Management 

Emergency Call Numbers: 757-810-8673 or 757-870-3472

Safety 

Emergency Call Number: 757-870-3472

All Other Incidents

For all incidents involving injury or damage to city property, please contact Risk Management by using the information below:

Risk Management

During business hours, Monday-Friday, 8 a.m.-4:30 p.m. Office: 757-727-6617 Fax: 757-727-1470 After-hours and/or emergency: 757-810-8673 or 757-870-3472 Email Risk Management

All oher non-work-related incident forms are listed below. Please never hesitate to contact Risk Management at 757-727-6617 or 757-870-3472 should you have any questions regarding the forms.

Public Works, Coliseum, Fleet Services, and Parks, Recreation & Leisure Services must also notify Safety on all injuries and property damage using the information below:

Safety

During business hours, Monday-Friday, from 7:30 a.m.-4 p.m. Office: 757-727-6386 Cell: 757-870-3472 (cell preferred)

After-hours and emergency: please use the cell number provided. Email Risk Management

Reporting forms available: You can click on any of the links below to access the forms:

• Property Damage Report (PDF)

This form should be used for all damage relating to city and/or citizen property.

• Non-Employee Incident Report (PDF)

This form should be used to report mishaps involving bodily injury of citizens, contractors, and volunteers.

• Hazardous and Non-Hazardous Spill Reporting Form (PDF)

For any spill (hazardous material release) over 5 gallons, it is mandatory that the Hampton Fire Department's Hazmat team be notified by dialing 911.