Incident Report Form

The purpose of this form is to report any incidents or injuries that occur at properties under the GTJ umbrella.  This survey is open to GTJ’s Employees, Business Partners as well as the General Public.  All incident report submissions are reviewed carefully by GTJ’s Senior Management.  In the event you have been involved in an incident, please fill out this form accurately & completely.  Also, please note there are sections that permit photos and files to be submitted as needed.  If you need immediate attention, please contact the GTJ Headquarters at (586) 293-9600 or call the GTJ 24-Hr Emergency Hotline at 1-800-385-0563.  Thank you for your time.

Submission Type: *

• GTJ Employee
• GTJ Business Partner
• General Public

Report Type: *

• Incident
• Injury

The purpose of this form is to report any work-related injuries that have occurred while working at GTJ. In the event an injury requires medical attention, please seek treatment This form is intended for GTJ staff and submission is required to document all work-related injuries. Please note there are sections that permit photos and files to be submitted as needed. If you need immediate attention, please contact the GTJ Headquarters at (586) 293-9600 or call the GTJ 24-Hr Emergency Hotline at 1-800-385-0563. Thank you for your time.

Company Name: *

Name of Person Submitting Report: *

First

Last

Phone #

Email Address of Person Submitting Report: *

Name of Person Injured: *

First

Last

Select your direct reporting Manager's Name:Select Direct Reporting ManagerBlake JohnsonRyan WiseJason KnollKyle JohnsonRyan ConleyTracy Sams

Names of all people involved in incident: *

Date / Time Of Incident: *

Date

Time

Date / Time of Injury: *

Date

Time

Location of Incident: *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Location of Injury : *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Please select option(s) that best describe the incident: *

• Accident
• Interaction with Homeowner
• Interaction with Neighbor
• Interaction with Police
• Missing or Damaged Equipment
• Missing or Damaged Property
• Problem with Services Provided
• Theft
• Other

Did you Report the Injury to your Manager immediately? *

• Yes
• No

Please list the names of all people present / witnessed the Injury: *

Please describe the injury and the area(s) of body injured as a result of the incident: *

What object of substance caused the direct harm? *

Please provide detailed description of Incident resulting in the Injury: *

Was the Injury a result of work-related activities? *

• Yes
• No

Does this injury require medical attention? *

• Yes
• No

Please rank the severity of the injury: *12345

1 = Minor 5 = Severe

Please provide detailed description of incident: *

Do you have photos of incident to upload? *

• Yes
• No

Incident photo: *

Click or drag files to this area to upload. You can upload up to 5 files.

.jpg, .gif

Did you contact a GTJ Rep from the property to report the incident? *

• Yes
• No

Name of GTJ Representative: *

First

Last

Was nature of the incident resolved while on site? *

• Yes
• No

Is additional follow up needed from a GTJ representative regarding this incident? *

• Yes
• No

Is additional follow up needed from your Manager regarding this incident? *

• Yes
• No

Please provide names and contact information for any third parties involved in this incident:

Do you have any documents pertaining to this incident to update: *

• Yes
• No

Incident document: *

Click or drag files to this area to upload. You can upload up to 3 files.

valid file types are .pdf, .jpg, .gif, .xlxs, .xls, .doc, .docx, .txt and .csv

General Comments:

Phone

Submit