Accident / Injury / Incident Report (311 Form)

Please use the form below to report all incidents, injuries and illnesses.

If you are reporting a fatality, amputation, loss of an eye or overnight hospitalization, call (269)387-5588 immediately.  Then complete the form below.

Page 1: Start (current) Page 2: Preview Page 3: Complete
Please use the injured party's full name, no nicknames or acronyms.
Include Street Address, City, State and Zip Code.
Enter number with no dashes or spaces: ##########
Please indicate what room or floor the incident occurred in.
(Select "Yes" if they are going to see or went to see a health professional. Select "No" if the person received first aid that occurred on site or no assistance.)
Describe the activity, as well as the tools, equipment or material the person was using. Be specific. Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from hand sprayer", "daily computer entry."
Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet", "Worker was sprayed with chlorine when gasket broke during replacement", "worker developed soreness in the wrist over time."
You may choose more than one body part. (Hold down the Ctrl key to select multiple choices.)
Which side of the body did the injury occur?
Use this field to document anything additional regarding the injury. You can also use this field to list body parts that are not in the drop down menu.
Choose all that apply. Press and hold the Ctrl key to select multiple choices.
Examples: "concrete floor", "chlorine", "radial arm saw."
Please upload photos of the injury source, location-area, or anything else that may be helpful.
Files must be less than 300 MB.
Allowed file types: gif jpg jpeg png bmp eps tif pict psd txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods xml avi mov mp3 ogg wav.
Is there any additional information you would like to add before submitting this incident?
Were there any witnesses? Please tell us their name(s) and phone number(s).
Supervisor at the time of the incident.
Please enter phone number with no spaces or dashes ##########
Add the employee's email address if they wish to have a copy of this report sent to them.
Use this box to enter an email address used by your department director. Separate additional email addresses with commas.