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Administration

Administration, Finance, Human Resources, and Member-Client Services

Employment Portal

Incident/Accident Report

All reports will be reviewed with one (1) buisness day.

Type of Report

Who is submitting this report?

First Name

Last Name

Job Title

Email

Person involved in accident/near miss/incident:

First Name

Last Name

Nature of the event:

Did an injury occur? *

Yes

No

Medical treatment required? *

Yes

No

Name of facility, hospital or physician:

If yes, what type?

First Aid (On-site)

Urgent Care (Promt Care)

St. Michael Hospital/ED

Body part(s) affected:

Describe Event or Incident

Please describe the event:

Identify the factors that you believe contributed to or caused the incident:

I declare that the info I’ve provided is accurate & complete

Initials

Report Submitted

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About Peninsula Alliance

Since 1938, Peninsula Alliance has provided services locally to tens of thousands of individuals with developmental disabilities and their families throughout the Olympic Peninsula region. We have tirelessly promoted the acceptance and inclusion of people of all abilities, advocated for the most current research-based improvements, and opened new doors in helping people achieve a lifetime of success.

Our Locations

Administrative Office

400 Warren Avenue, Suite 305

Bremerton, WA 98337

Phone: 360.377.3473

Fax: 360.824.7149

©2025 Peninsula Alliance a 501(c)(3) Nonprofit Organization. | Terms of Use | Privacy Policy

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