South Washington County Schools Employee Incident Report Form - sowashco k12 mn 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Claim Information' section. Enter the employee’s name, last four digits of their Social Security number, home address, and contact details clearly.
3. Indicate the employee's gender, date of birth, marital status, date of hire, occupation, and department. Ensure all fields are completed accurately for proper documentation.
4. In the 'Date of Injury' section, specify when the incident occurred along with the time. Indicate whether it happened at work and provide details if it occurred elsewhere.
5. Describe how the accident happened in detail. This is crucial for understanding the context of the incident.
6. Complete the 'Injury Description' section by shading in the affected area on the body diagram and noting any hospitalization status.
7. Fill out medical treatment information if applicable, including physician or clinic details.
8. Finally, ensure both employee and supervisor signatures are included along with dates before submitting.

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