Marysville School District Standard Tort Claim Form Packet Page 4

11. District site or department alleged responsible for damage or injury:

12. Names, addresses and telephone numbers of all persons involved in, or witness to, this incident.

13. Names, addresses and telephone numbers of all District employees having knowledge about this incident.

14. Names, addresses and telephone numbers of all individuals not identified in #12 and #13 above that

have knowledge regarding the liability issues involved in this incident, or knowledge of the

Claimant’s resulting damages. Please include a brief description as to the nature and extent of

each person’s knowledge. Attach additional sheets, if necessary.

15. Describe the cause of the injury or damages. Explain the extent of the property loss or medical,

physical or mental injuries. Attach additional sheets, if necessary.

16. Has the incident been reported to the administration, security, or law enforcement? If so, when

and to whom?

Rev 8/21/15

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Parent category: Legal