Fillable EMPLOYEE SECTION Employee Department Job Position Supervisor Location (City of Eugene ISD)

Fill Online, Printable, Fillable, Blank EMPLOYEE SECTION Employee Department Job Position Supervisor Location (City of Eugene ISD) Form

Use Fill to complete blank online CITY OF EUGENE ISD (OR) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

EMPLOYEE SECTION Employee Department Job Position Supervisor Location (City of Eugene ISD)

On average this form takes 8 minutes to complete

The EMPLOYEE SECTION Employee Department Job Position Supervisor Location (City of Eugene ISD) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Eugene ISD

BROWSE CITY OF EUGENE ISD (OR) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Employee Department
EMPLOYEE SECTION
Job Position
Location of Incident
Supervisor
City Property
Date of Incident
Date Incident Reported Incident Reported To
Injury description
Task that led to injury
Incident description
Employee Signature_____________________________________________
Yes No
Time
AM PM
Date
Root causes and
contributing factors
Root causes and contributing factors may include things like:
-Other people -Animals -Equipment failure -Environmental hazards
-Fatigue -Overexertion -Lack of training -Repetitive motion
-Weather -Lack of PPE -Rules violation -Housekeeping
Preventative measures
Print Form
Reset Form
SUPERVISOR SECTION
801 Submitted
Yes No
Hospitalization / Fatality
Yes No
Does Injury involve days away from work?
Yes No Yes No
Does injury involve restricted work activity?
Incident description
Root causes and
contributing factors
Preventative measures
Supervisor's Signature _______________________________________________
Date
Date
Reviewed By _______________________________________________________
Submit this report to Risk Services at 940 Willamette Street, Suite 200, Eugene, OR 97401.
Root causes and contributing factors may include things like:
-Other people -Animals -Equipment failure -Environmental hazards
-Fatigue -Overexertion -Lack of training -Repetitive motion
-Weather -Lack of PPE -Rules violation -Housekeeping
Reset Form
Print Form
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

EMPLOYEE SECTION Employee Department Job Position Supervisor Location (City of Eugene ISD)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document