JAX Safety Reporting

If this is an emergency, stop filling out this form and call 911.

This page is designed to help you navigate the various ways in which we document safety concerns. In the field below where it asks why you are here, use the criteria to select an option. The form will guide you through the rest of the process.

Select “First Report of Injury” if you are a JAX employee injured on the job, a coworker who witnessed a job-site injury, or are a store manager acknowledging the injury and documenting future efforts to prevent similar injuries.

Select “Incident Report” for situations where a customer was injured, JAX property was damaged or stolen, there was a medical emergency, or where there was an incident that may need to be reported for general liability concerns.

Select “Safety Incident or Concern” if you need to document something that could cause harm to JAX employees or customers or put them at risk. You’ll have the option to select if the matter is urgent – needs to be solved within 48 hours, or not urgent – needs to be fixed but it’s not an immediate danger, or needs to be documented for future reference. This is a form that is completed to prevent incidents by identifying issues or documenting patterns.

– Step 1 of 3

I'm here to document a(n)… *Select OneSafety Incident or ConcernFirst Report of Injury / Witness StatementIncident Report / Witness Statement

JAX Location *Select OneJHO – JAX Home OfficeAOD – JAX AmesJOD – JAX Outdoor Fort CollinsFNR – JAX Farm Fort ColinsJML – JAX Loveland EastJLW – JAX Loveland WestJLF – JAX Farm LafayetteJLA – JAX Outdoor LafayetteJBR – JAX BroomfieldJCH – JAX CheyenneOTHER

Select your location

I am… *Select OneAn Employee who was injuredA Witness who saw an injuryA Manager reporting an injury

Select your role

I am a… *Select OneManager documenting an incidentWitness to an incident

Today's Date *

Next

Safety Incident or Concern

Please tell us more about any safety concerns you have identified or an incident which should be documented to prevent future incidents or discover patterns.

My safety incident or concern … *Select OneIs Urgent – Needs to be fixed ASAPIs Not Urgent – Needs to be fixed but can be handled at a later timeNeeds to be documented for future reference

I'd like to report a… *Select OneThreatening / unusual / concerning behaviorNuisance / panhandling / scam potentialSuspected shopliftingGeneral Maintenance Issue (slow water leaks, broken locks, burnt out light bulbs etc…)Structural Issue (large cracks in floor or walls, holes in roof or ceiling, unsafe stairwells etc…) Electrical issue (exposed wires, faulty outlets or switches, localized outages, etc.)Fire prevention or evacuation route issue (expired fire extinguishers, blocked emergency exits, open flames, etc.)Indoor Air Quality Issue (exposed chemicals or fuels, faulty vent fans, debris coming from vents, etc.)PPE Issue (If you think you should have been provided PPE and were not, or provided the wrong type of PPE)Other (please describe)

Date / Time of the Incident

Date

Time

Only enter a date and time if applicable.

Please describe the safety incident or concern *

If documenting an incident: Include a thorough description of what happened, who it happened to, where it happened, and how we could prevent the incident from happening again. Include any details that may be relevant in the future. If documenting a concern: Include the location, a description of the problem, and who it affects (specific departments, customers, individuals etc…). Please include recommendations to fix or resolve the problem if you have suggestions.

Name of Person of Concern, if known

First

Last

This field is optional and only should be completed if you know their name. If you only know nick-names or if there are multiple people involved, please put that information in the description of the safety concern.

File Upload for images, video, sound, etc.

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload a file here if you have a photograph, video, sound-recording or other identifying document that may help in the future.

Action Taken

What action, if any, was taken?

Name (Your name and contact information will not be shared with store team members and will only be used if we need more information) *

First

Last

Preferred phone number *

Preferred email address *

First Report of Injury: Employee Statement

Please fill out the information below related to your workplace injury.

——————————

If you are a manager filling out this section on behalf of an employee, fill this out as if you were the injured employee. If you are unsure of an answer please type “Unknown”, HR may reach out to you at a later date if any clarification is needed.

Please tell us your first and last name *

First

Middle

Last

Your date of birth *

Gender *

• Male
• Female
• Prefer not to say

What is your job title? *

When were you injured? *

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Date

Time

Please note the date and time the injury occurred. When you note the time. Please specify AM or PM.

What time did you begin work on the day of your injury? *

Did the incident occur on premise? *Select OneYesNo

Specifically, where were you when the injury happened? *

What specific body part was injured? *

What object or substance directly impacted you? *

What were you doing just before the accident occured? *

Please describe the accident and be as descriptive as possible. Where were you, what type of equipment were you using, what job were you trying to complete, were you wearing any protective equipment, what were the conditions around you like? *

Did your injury require treatment? *Select OneYesNo

What type of treatment? *

• Minor on-site
• Clinic/Hospital
• Emergency Room
• Hospital for longer than 24 hours

Did you return to work after the injury? *Select OneYesNo

What date/time did you return to work? *

Date

Time

Have you previously been injured on the job? *Select OneYesNo

Please note the date of previous injury. *

Was this injury an aggravation of, or re-injury to, an existing condition? *Select OneYesNo

Please provide approximate date and nature of existing injury. *

Witness Names & Manager Information

Who witnessed your injury? Person 1

First

Last

Who witnessed your injury? Person 2

First

Last

Who witnessed your injury? Person 3

First

Last

Who was your injury reported to? *

First

Last

What date was your injury reported? *

What is your supervisor's name? *

First

Last

How can we contact you?

Current Address *

Address Line 1

Address Line 2

City

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

Zip Code

Preferred phone number *

Preferred email address *

I have received a list of designated medical providers who can provide treatment for work-related injuries.YesNoWill obtain later

Sign below by typing your full name *

First Report of Injury: Supervisor Statement

Please tell us your name. *

First

Last

Please tell us your title *

I am responding to the injury report for… *

First

Last

Who was injured on… *

Date the injury was reported *

I have provided the list of Designated Medical Providers for treating work-related injuries.

• Yes
• It will be provided within 24 hours of this report

I am aware of this employee's work-related injury or accident, and i have taken the neccessary steps at this work site to ensure this type of injury or accident does not occure again. *

• Yes

Please note the steps taken to prevent similar injuries or accidents. *

Sign below by typing your full name *

Witness Statement

Please tell us your name *

First

Last

Please tell us the name of the coworker who was injured *

First

Last

Please describe the accident and be as descriptive as possible. Where were you when it happened, what type of equipment were you or the person who was injured using, what job were you or that person trying to complete, was that person wearing any protective equipment, what were the conditions around you and that person like? *

Please describe the incident and be as descriptive as possible. Where were you when it happened, what did you see, who was involved, when did it occur, how long did it take? *

What were you doing at the time of the accident? *

What were you doing at the time of the incident? *

Any additional comments or observations?

Please sign by typing your name below. *

Incident Report – Manager Documentation

This is the form to complete when you are documenting a customer who was injured, damaged or stolen JAX property, a medical emergency or other incidents that may need to be reported for general liability concerns.

Your Name *

First

Last

Your Store Address *JOD – 1200 North College Avenue, Fort Collins, CO. 80524FNR – 1000 North Highway 287, Fort Collins, CO 80524AOD – 4723 West Lincoln Way, Ames, IA 50014JML – 950 East Eisenhower Blvd., Loveland, CO 80537JLA – 900 South Highway 287, Lafayette, CO 80026JLF – 400 South Boulder Road, Lafayette, CO 80026JLW – 2665 West Eisenhower Blvd., Loveland, CO 80537JBR – 5005 West 120th Avenue, Broomfield, CO 80020JCH – 1400 Dell Range Blvd., Cheyenne, WY 82009JHO – 4629 North Overland Trail, Laporte, CO 80535Other

Please select the address of the incident. If the address is “Other”, please indicate the location of the incident in your description.

Your Preferred Phone Number *

Your Preferred Email Address *

Date and Time of the Incident *

Date

Time

Name of the Manager on Duty While the Incident Occured *

First

Last

Date and Time the Incident Was Initially Reported *

Date

Time

Who was the incident reported to? *

First

Last

Who was the incident reported by? *

First

Last

Describe the incident including any detail about injuries or loss that occurred. Please include all the names of people involved. *

Was Law Enforcement and/or Medical Responders Dispatched? *YesNo

Responding Law Enforcement Officers name and contact information

Witness to the incident (Person 1)

First

Last

Witness to the incident (Person 2)

First

Last

Witness to the incident (Person 3)

First

Last

I am aware of this incident and i have taken the necessary steps at this work site to ensure this type of injury or accident does not occur again. *

• Yes

Please note the steps taken to prevent similar incidents. *

Please sign by typing your name below. *

Next

Submit