Department of

Human Resources

Our Goal is to ensure that we provide the best possible service to our current employees, prospective employees, retirees, and the citizens of Racine, thus making the City an employer of choice and a great place to work! We are responsible for personnel services and policies and overall employee relations for the City of Racine. We are dedicated to providing quality service to current employees, as well as to individuals seeking employment with the City.

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Wellness Incentive Program

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About the HR Department

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Employee First Report of Incident Form

Report Workplace Incidents Promptly

Complete the First Report of Incident Form to document any workplace injuries or accidents. Your report ensures timely support and helps us maintain a safe working environment.

Doctor listening to a young girl's heartbeat with a stethoscope, mother present. Child smiling during checkup.

CITY OF RACINE EMPLOYEE’S FIRST REPORT OF INCIDENT

Name(Required)

First Name Middle Name Last Name

Email(Required)

Employee Home Telephone No.(Required)

Occupation(Required)

Address(Required)

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code

Birth Date(Required)

Date of Hire(Required)

County and State where accident or exposure occurred(Required)

Injury Date Mo/Day/Yr(Required)

Time of Injury(Required)

Last Day Worked(Required)

Date Employer Notified Mo/Day/Yr(Required)

Shift Working at time of incident (i.e., 7:00 – 4:00)(Required)

Did you leave work(Required)

Yes

Estimated Date of Return:(Required)

Location where injury occurred‐be as specific as possible(Required)

Were you or do you anticipate being treated by a medical professional for this injury or illness?(Required)

Yes

Were you hospitalized for this injury or illness?(Required)

Yes

Name and address of medical professional and/or Hospital:(Required)

Area of Injury(Required)

Specify(Required)

Type of Injury(Required)

Specify(Required)

Injury Description: Describe your activities when injury or illness occurred and what tools, machinery, objects, chemicals, etc. were involved. (Use additional page if necessary)(Required)

What happened to cause this injury or illness? (Describe how the injury occurred. Use additional page if necessary)(Required)

Describe your injury or illness. (State the part of body affected and how it was affected. Use additional page if necessary)(Required)

Additional Page(s) attached.(Required)

Yes

Witness (es)‐Names of all employees and non‐employees who witnessed your injury or illness. (Use additional page if necessary)(Required)

Witness Signature(Required)

Date Signed(Required)

Supervisor Signature(Required)

Date Signed(Required)

Report Submitted By:(Required)

Work Phone(Required)

Position(Required)

Date Submitted(Required)

Fax This Form to Human Resources at 262‐636‐9585

Phone

This field is for validation purposes and should be left unchanged.

Download Fitness Center Reimbursement Form

About City of Racine Human Resources

Welcome to the City of Racine’s Human Resources Department. Our dedicated team is committed to empowering employees, fostering a positive and productive workplace, and recruiting top talent to serve our community. Learn more about our values, goals, and the services we provide to support the city’s continued growth and success.

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