City Of Portland Recording Form: Accident / Incident / Illness

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For OSHA recordkeeper:
City of Portland
Recording Form: Accident / Incident / Illness
Record to 300 Log
The DCBS Form 801 is still required for submitting a Workers’ Compensation claim.
Do not record to 300 Log
Employee Section
Employee’s name:
Work phone:
Bureau:
Supervisor name:
Work phone:
6
12
18
2
3
5
10
Length of time in present job, less than:
months
months
months
years
years
years
years
Exact location of accident/incident:
:
a.m.
p.m.
Yes
No
Date of incident:
Time:
Were there any witnesses?
Name:
Phone:
Name:
Phone:
Witnesses:
Name:
Phone:
Name:
Phone:
What body part was affected (check all below that apply):
Head / Face
Shoulder
right
left
Buttocks
right
left
Eye(s)
Lips/teeth/tongue
Neck
Arm pit
right
left
Hip
right
left
Ear(s)
Finger(s)
Back, upper
Upper arm
right
left
Thigh
right
left
Nose
Toe(s)
Back, lower
Elbow
right
left
Knee
right
left
Other
Chest
Lower arm
right
left
Lower leg
right
left
Other
Abdomen
Wrist
right
left
Ankle
right
left
Pelvis/groin
Hand
right
left
Foot
right
left
What task led to the incident (check all below that apply):
Driving
Sitting
Walking
Bending
Carrying
Pushing
Reaching
Keyboarding
Riding
Crawling
Running
Twisting
Handling
Pulling
Lifting
Mousing
Other (describe):
Describe accident/incident in detail (use additional sheets if necessary):
Employee signature:
Date:
* Employee, forward immediately to your supervisor.
Management Section
Reported to:
Date:
Time:
:
a.m.
p.m.
Description of incident (what happened and why):
Corrective action (use additional sheets if necessary):
Print name of the person
Bureau:
Phone:
who filled out this section:
Signature:
Work unit:
Date:
*Supervisor, identify and forward immediately to the appropriate recipient:
 Safety Representative
 300 Log Recordkeeper
 Human Resources
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