Fillable Non-Injury Employment Incidents Standard Liability Incident Report (Rogers State University)

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Non-Injury Employment Incidents Standard Liability Incident Report (Rogers State University)

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DCAM/RISK MGMT - FORM 001c (06/2019)
PAGE 1 OF 1
OMES RISK MGMT P.O. BOX 53364 OKLAHOMA CITY, OKLAHOMA 73152 TEL: 405-521-4999 (24h), FAX: 405-522-4442
Non-Injury Employment Incidents
Standard Liability Incident Report
Claim number
Incident date Time Date of agency notification
Claim form requested? Yes No
Location
Address/highway City State County
Employee Information
Name Phone
Address City State Zip
Email address
Agency Information
Agency name Agency # Phone
Div. or dept. Address
Type of Issue
Termination Sexual harassment Constitutional rights Civil rights Failure to promote
Discrimination of Misrepresentation Other
Describe incident, include any co-workers involved
Wi
tnesses
Name Address Phone
Attach supporting documentation: PMPs, Progressive Discipline, EEOC, court documents, emails, etc.
Risk coordinator signature Risk coordinator printed name Date
Email Phone number
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signature
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Non-Injury Employment Incidents Standard Liability Incident Report (Rogers State University)

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Completed 9 February 2021

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