M
MLEAIncident Reporting
EMPLOYEE REPORT
SAFETY FIRST

Tell us what happened.

One report covers injuries, vehicle incidents, property damage, and near misses. Answer a few questions and the form adjusts automatically.

Emergency? Call emergency services and contact your supervisor immediately. This form does not dispatch emergency responders.
01

What happened?

Select Yes for everything that applies to this incident.

Was anyone injured?Injury or illness, even if treatment was minor
Was any property or equipment damaged?MLEA, customer, or other property
Was a vehicle involved?Collision, backing, rollover, or vehicle incident
Was this a near miss?Something almost happened but no injury or loss
02

Incident information

These details will appear on each applicable report.

Weather conditions (select all that apply)
For injury reports, the official 122E allows up to 180 characters.
03

Employee injury details

Complete the details needed for the injury report.

Use 111-11-1111. Confidential — only in the protected 122E.
Dollar amount with up to two decimal places.
Weekly wage is calculated automatically.
03

Property or equipment damage

Record what was damaged and who owns it.

03

Vehicle collision / incident

Use the information available at the scene; additional insurance details may be added to the narrative.

Road conditions (select all that apply)
Traffic conditions (select all that apply)
Visibility / lighting (select all that apply)
Weather at time of collision (select all that apply)
Traffic controls (select all that apply)
Other vehicle movements (select all that apply)

Other driver / vehicle / insurance

Additional third-party vehicles

Use Add Another Vehicle for each vehicle beyond the first other vehicle above. Up to 8 more vehicles.

03

Near miss details

Keep it simple: what almost happened and how to prevent it.

04

Photos and signature

Include supporting images and certify the report.

5 MB maximum each. Images are encrypted in the database.
05

Review and submit

Check your answers and the documents that will be prepared.

Your report is encrypted and stored in MySQL. A copy of the generated reports will be sent to the office and employee email address.