This is the form used by Logan County. Brian Dunn Projects Coordinator Logan County Commissioners (937) 599-7280 office (937) 599-7268 fax From: CORSA-broadcast <corsa-broadcast-bounces@corsa.org> On Behalf Of Hardin EMA Sent: Thursday, August 30, 2018 3:57 PM To: 'CORSA Broadcast Email' <corsa-broadcast@corsa.org> Subject: [CORSA-broadcast] Incident report Hardin County is looking to update their Unusual Incident Report, a one-page form that any county employee can complete when they observe or notice an accident, injury, or any unusual event or circumstance that may involve a member of the public, county property, or county employee. This is separate from a BWC Employee Report of Injury or Illness, but would include some of the same information in some circumstances. Would any county be willing to share anything they use that might help us improve our form? Thank you, Max Trachsel Hardin Co. EMA & Loss Control 419-674-2276 This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain private, confidential and/or privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, employee or agent responsible for delivering this message, please contact the sender by reply e- mail and destroy all copies of the original e-mail message. According to Ohio Public Records Law written communications to or from agencies/staff regarding this agency are public records and may be available to the public and media upon request. Your e-mail may be subject to public disclosure.

Darke County's Incident Form John M. Cook Facilities & Safety Manager Darke County Phone: (937) 547-7302 Cell: (937) 459-2267 Fax: (937) 547-2907 "The secret of getting ahead is getting started." ~ Mark Twain From: CORSA-broadcast <corsa-broadcast-bounces@corsa.org> On Behalf Of Hardin EMA Sent: Thursday, August 30, 2018 3:57 PM To: 'CORSA Broadcast Email' <corsa-broadcast@corsa.org> Subject: [CORSA-broadcast] Incident report Hardin County is looking to update their Unusual Incident Report, a one-page form that any county employee can complete when they observe or notice an accident, injury, or any unusual event or circumstance that may involve a member of the public, county property, or county employee. This is separate from a BWC Employee Report of Injury or Illness, but would include some of the same information in some circumstances. Would any county be willing to share anything they use that might help us improve our form? Thank you, Max Trachsel Hardin Co. EMA & Loss Control 419-674-2276