Employee Incident Report If you seek medical treatment, call the ESD 113 Workers' Compensation Trust at (360) 464-6880 to file a claim.School district * RequiredAberdeenAdnaArlingtonBoistfortCentraliaChehalisCosmopolisElmaESD 113ESD 113 Early LearningEvalineGrapeviewGriffinHood CanalHoquiamLake QuinaultMary M KnightMcClearyMontesanoMortonMossyrockNapavineNorth BeachNorth RiverNorth ThurstonOakvilleOcostaOlympiaOnalaskaPe EllPioneerRainierRaymondRochesterSatsopSheltonSouth BendSouthsideTaholahTeninoToledoTumwaterWhite PassWillapa ValleyWinlockWishkah ValleyYelmSchool name * RequiredBuilding Location Name (i.e. Green Elementary; District Office; Shady Glen High School)Employee's full name * Required Mr.Mrs.MissMs.Dr.Prof.Rev. 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the mailing address the same as the physical address?YesNoHome mailing address * Required Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary phone contact number * RequiredWork phone contact number * RequiredJob title * RequiredTeacher, Custodian, Assistant, etc.Department * RequiredAdministration, Food Service, Instruction, Maintenance, SPED, Transportation, etc.Supervisor's name * RequiredFirst and lastSupervisor's email * Required Supervisor's phone * RequiredShift hours (start and end times) * Requiredi.e. 8:00 am to 3:00 pmDate 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 AM PM Location of injury * RequiredExample: Field trip to the pumpkin patch, sporting event at school, en route/travelingDid incident occur ON or OFF school premises? * RequiredOn school groundsOff school groundsIf incident occurred off school premises, please provide location.Description of injury * RequiredPlease provide a brief description of the incident/injury.Were you doing your regular work? * RequiredYesNoBody part(s) injured * RequiredExample: Left leg, right elbow, low back, head, left middle toe, etc.Type of injury * RequiredExample: Bruise, cut, scratch, sprain, strain, fracture, etc.Reported incident to * RequiredProvide 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 * RequiredProvide witness name, or if none enter "None"Seeking medical treatment? * RequiredYes - If yes: Contact ESD 113 WCT at 360-464-6880 to file a claimPossiblyNoAre you able to keep working?YesNoReturn to work date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Leave blank if not sureLast date worked? - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Employee report code
