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 * RequiredAberdeenAdnaArlingtonBoistfortCentraliaChehalisCosmopolisElmaESD 113ESD 113 Early LearningEvalineGrapeviewGriffinHood CanalHoquiamLake QuinaultMary M KnightMcClearyMontesanoMortonMossyrockNapavineNorth BeachNorth RiverNorth ThurstonOakvilleOcostaOlympiaOnalaskaPe EllPioneerRainierRaymondRochesterSatsopSheltonSouth BendSouthsideTaholahTeninoToledoTumwaterWhite PassWillapa ValleyWinlockWishkah ValleyYelmSchool name * Required Building 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 MM slash DD slash YYYY Employee email * Required Physical home address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the mailing address the same as the physical address? Yes No Home mailing address * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary phone contact number * RequiredWork phone contact number * RequiredJob title * Required Teacher, Custodian, Assistant, etc.Department * Required Administration, Food Service, Instruction, Maintenance, SPED, Transportation, etc.In which language do you prefer to communicate? Supervisor's name * Required First and lastSupervisor's email * Required Supervisor's phone * RequiredShift hours (start and end times) * Required i.e. 8:00 am to 3:00 pmDate of incident/injury - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Time of incident/injury * Required : Hours Minutes AM/PM AM PM AM/PM Location of injury * Required Example: 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 * 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 MM slash DD slash YYYY Witness(es) to incident * Required Provide 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 MM slash DD slash YYYY Leave blank if not sureLast date worked? - must be mm/dd/yyyy format MM slash DD slash YYYY Employee report code
