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SOESD Employee Incident Report

 
* Employee Name 
* Employee Job Title 
* Employee Work Site 
* Date of Incident 
* Time of Incident 
* How Incident Occurred (be specific) 
* Where Incident Occurred 
* Type of Injury 
If you chose "Other" for "Type of Injury", please clarify: 
* Part of Body Affected (distinguish right and left) 
* Are you intending to see a doctor? (if not, and you do end up seeing a doctor at a later time, please let us know immediately)Yes No 
* What type of treatment did you receive for your injury? 
* Names of any Witnesses 
 
 
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SOESD
SOESD
SOESD
101 North Grape Street
Medford, OR 97501
Phone: 776.8590 or 800.636.7450
Fax: 541.779.2018
Email Us
Hours: 7:30 - 4:30 Mon - Fri
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