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Public Works Citizen Incident Report

  1. Instructions

    FILL IN ALL BLANKS.  If a blank does not apply to your accident, injury, or illness, then write “N/A” in the blank.  

  2. Sex*
  3. Parent or Guardian Contact Information:
  4. Sex*
  5. Details of the incident:
  6. AM/PM*
  7. Did Police of Emergency personnel respond?*
  8. Attach the following documents, if relevant and available: Photos, signed waivers, quote/estimate, medical bills, receipts, posted warning signs, maintenance records/work orders on incident location:
  9. Optional


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  13. Optional

  14. Optional

  15. Optional 

  16. Optional

  17. Leave This Blank:

  18. This field is not part of the form submission.