Incident Report | Omak Washington

Incident Report to be filled out for any incident.

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Date of Injury

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Time *

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Time AM

Time PM

Type of Incident (Check all that apply) *

Injury/condition requiring no professional medical attention

Injury /condition requiring professional medical attention

Vehicle Accident

Security Incident

Hazardous Condition

1.Name: Last, First, MI *

2.Age *

3.Employee's ID# *

Address

4.Mailing Address *

City *

State *

Zip Code *

5.Phone Number *

6.Job/Position Title *

7.Start Time of Shift *

8.Work Schedule *

9.Supervisors Name *

10.Assigned work location (Facility/Office Name and Address) *

11.Exact Location of incident (BLDG, ROOM, BODY OF WATER, ECT.) *

12.In Travel Status *

Yes

If Other Specify

If Other/Toxin

16.Body Part Affected (be specific) *

17.Detailed Description of how incident (or hazardous condition) occurred (Attach additional pages if necessary) *

18.Is this an aggravation of a previous injury/symptom? *

Yes

If yes when were you last treated?

By whom or where?

19.To whom did you report the incident?

Name *

Phone *

Date *

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Time *

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Time AM

Time PM

Witness(es): (Attach additional pages if neccessary)

Attach additional pages here

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png bmp tif html pdf doc docx xls xlsx avi mp3.

Contact Information

Address
P.O. Box 72 | 2 N Ash St. | Omak, WA 98841

Phone
509-826-1170

View Full Contact Details

City of Omak | P.O. Box 72 | 2 N Ash St. | Omak, WA 98841 | 509-826-1170