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2. This form may be used to report injury or damage by a County employee or that involves a County-owned vehicle or property. 

   Please complete all applicable fields. You will receive a response from staff within two business days. If you need is urgent, you can may also contact Paul Brunner at 301-600-1425.

4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip*
13. Phone #1*
14. Phone #2
15. Reply Email*
17. Date of Incident*
    Date of Incident
18. Time of Incident*
    Time of Incident
19. Location of Incident. Please be specific.*
21. Fully describe how the incident occurred. Please include the police report number, if applicable.*
23. Describe the specific injury or property damage in detail. If the incident involved a vehicle, please provide the make, model, and VIN.*
25. File Upload 1

    If photos or videos of the incident are available, please upload here.

26. File Upload 2
27. File Upload 3
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field