Omd, Agp Accident Illness Report Form Page 5
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5Oregon Military Department
Employee Incident/Accident Report
To be completed by employee:
1. Describe your work activity prior to and up to the time of accident.
2. Describe exactly what happened:
3. Describe what cause or causes attributed to the accident? (your actions, equipment, other factors)
4. Were you aware of the hazard prior to this incident (i.e. signs, hazard identified)? If so, describe how you
became aware of it (i.e. reported to supervisor prior? If so, whom?)
5. Describe the type of medical treatment you received (if any):
Treatment:
None
First Aid Only
Doctor
Hospital
6. List any witnesses to the Incident/Accident:
Oregon Military Department - AGP
October 2011
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