Employee and Supervisor Incident Reporting

To maintain a safe and accountable workplace, all incidents involving injury, exposure, property damage, or near-misses must be properly documented. The City of San Rafael utilizes two key forms for this process, and the Fire Department uses a third:

1. Seek Medical Attention:
   No matter how small, if you get injured at work, seek medical attention immediately.
2. File Claim Paperwork (Employee & Supervisor):
   Worker's Compensation claim paperwork is available through HR here https://employees.cityofsanrafael.org/workers-comp-forms/on the Human Resources page, or BELOW. Follow the instructions, sign where indicated, and share with your supervisor and administration ASAP.
   
   

   • DWC 1 from (Employee):
     This form must be completed by the employee involved in the incident as soon as possible after the event. Please provide clear, factual details about what occurred, where and when it happened, and any contributing factors. Submit the completed form to your supervisor within 24 hours.

   • 5020 form, and Supervisor Investigation Report (Supervisor):
     Once notified of an incident, the supervisor must complete these forms promptly after reviewing the employee’s statement (DWC 1). These forms document the supervisor’s account of the incident, identify potential causes, and outline corrective actions or follow-up steps. The completed reports should be submitted to the Battalion Chief and the Administrative Office within 24 hours of the incident.

   • Supervisor's Investigation Report (Supervisor): 
     As soon as possible, and within 24 hours, the supervisor must complete the Supervisor's Investigation Report form (below). Adding the Supervisor’s Investigation Report strengthens our ability to identify contributing factors, track trends, and enhance workplace safety. It also supports faster claims processing and ensures the department remains compliant with state and city risk management requirements.

Timely and accurate reporting ensures we uphold the highest safety standards and allows for continuous improvement of our operational procedures.

If you have any questions about the reporting process, contact your supervisor or the Administrative Office.