Fillable Scope of Employment State agenc y name Agency (Rogers State University)

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Scope of Employment State agenc y name Agency (Rogers State University)

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File type: PDF

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Scope of Employment
DCAM-RISK MGMT P.O. BOX 53364 OKLAHOMA CITY, OKLAHOMA 73152 TEL: 405-521-4999 FAX: 405-522-4442
Incident date Time Claim No. (CAM use only):
Employee name Job title:
State agenc
y name Agency number
Division or dept.
P
hone
Address City State Zip
Type of employment: F
ull Time Temporary Volunteer Contract
Who authorized this specific duty?
Was employee aware of incident?
Ye
s No
Please describe in detail what specific duty was being performed at the time of the incident.
Employee signature
Employee name printed
D
ate
Supervisor signature
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ate
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Scope of Employment State agenc y name Agency (Rogers State University)

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Completed 9 February 2021

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