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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Supervisor Review of Injury or Illness Form

Ensuring Workplace Safety and Support

Complete the Supervisor Review Form to document and address workplace injuries or illnesses. Your input helps us maintain a safe and supportive work environment.

CITY OF RACINE Supervisor Review of Injury or Illness Form

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

Name(Required)

Employee Name Employee Middle Name Middle Last Name

Email(Required)

Injury Date Mo/Day/Yr(Required)

This form is to be completed by the employee’s supervisor. Please provide information that will supplement the employee’s report, noting circumstances which may have contributed to the injury or illness, such as weather conditions, use of protective safety equipment, etc. Be thoughtful and thorough, seeking to identify operations, procedures, use of equipment or modification that could help reduce future incidents.

UNSAFE ACT / CONDITION:(Required)

Specify(Required)

CONTRIBUTING FACTORS:(Required)

Specify(Required)

CORRECTIVE ACTION (Attach additional pages, if necessary):(Required)

Action to be Taken to Prevent Recurrence:

Responsible Party:

Completion Date:

Supervisor Signature:(Required)

Date Signed(Required)

Department Manager Signature(Required)

Date Signed(Required)

Download Supervisor Review of Injury or Illness 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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