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 * Required
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.
In which language do you prefer to communicate?
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 * Required
MM slash DD slash YYYY
Time of incident/injury * Required

: Hours

Minutes

AM/PM 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 * Required
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
MM slash DD slash YYYY

Leave blank if not sure
Last date worked?
MM slash DD slash YYYY
Employee report code

Employee Incident Report

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