Employee Incident Report

If you prefer to file a paper Employee Incident Report form, call the ESD 113 Workers' Compensation Trust at 360-464-6880. If you seek medical treatment, call 360-464-6880 to file a claim.
School district * Required
School name * Required
Building Location Name (i.e. Green Elementary; District Office; Shady Glen High School)
Employee's full name * Required
Prefix First Middle Last Suffix
Date of birth - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Employee email * Required
Physical home address * Required
Street Address Address Line 2 City State ZIP Code
Is the mailing address the same as the physical address?
- Yes
- No
Home mailing address * Required
Street Address City State ZIP Code
Primary phone contact number * Required
Work phone contact number * Required
Job title * Required
Teacher, Custodian, Assistant, etc.
Department * Required
Administration, Food Service, Instruction, Maintenance, SPED, Transportation, etc.
Supervisor's name * Required
First and last
Supervisor's email * Required
Supervisor's phone * Required
Shift hours (start and end times) * Required
i.e. 8:00 am to 3:00 pm
Date of incident/injury - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Time of incident/injury * Required

: HH

MM

AM/PM
Location of injury * Required
Example: Field trip to the pumpkin patch, sporting event at school, en route/traveling
Did incident occur ON or OFF school premises? * Required
If incident occurred off school premises, please provide location.
Description of injury * Required
Please provide a brief description of the incident/injury.
Were you doing your regular work? * Required
Body part(s) injured * Required
Example: Left leg, right elbow, low back, head, left middle toe, etc.
Type of injury * Required
Example: Bruise, cut, scratch, sprain, strain, fracture, etc.
Reported incident to * Required
Provide the name of the person you reported your incident to. If you did not report it, enter "Not Reported".
Date reported - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Witness(es) to incident * Required
Provide witness name, or if none enter "None"
Seeking medical treatment? * Required
Are you able to keep working?
Return to work date - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY

Leave blank if not sure
Last date worked? - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Employee report code

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