Employee Accident & Investigation Report Form
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1
2For HR use
Incident #: ________________
NYBEAS: ________________
C3 Sent: ________________
Safety Officer: ________________
Employee Accident & Investigation Report
A. Call the Accident Reporting System at 1-888-800-0029 Monday - Friday 8am to 5pm
B. Follow the directions on the second page of this form, please answer every question
C. Return this completed form to your supervisor for their review and signature
D. Please send to Human Resources: fax 746-4158 OR e-mail to humanresources@delhi.edu OR send inner office mail to HR: Bush Hall
Employee Name: __________________________________________ Bargaining Unit: _________________________________
Employee Address: ________________________________________________________________________________________
Date of Birth: ________________________________________
Female
Male
Social Security Number: ________________________________ Cell/Home #: _______________________________________
Job Title: ___________________________________________ Department: _________________________________________
Full Time
Part Time
Your date of hire: _____________________________________
Shift:_______________________________________________ Pass Days: ___________________________________________
Primary Work Location: ________________________________ Work Phone: _________________________________________
Work Address: ___________________________________________________________________________________________
Accident Date: _______________________________________ Time of Accident: _____________________________________
Location of Accident: ______________________________________________________________________________________
Type of Injury: ______________________________________ Body Part(s) affected: ___________________________________
After the accident, did you continue working?
Yes
No
Have you returned to work?
Yes
No
If yes, what date did you return? _________________________
No
If yes, what date?_____________________________
Yes
Did you require medical attention?
Name of Doctor: _________________________________________________________________________________________
Name & Address of Hospital: _______________________________________________________________________________
What were you doing when you where injured? (Please be specific: identify tools, equipment or material that you were using)
_______________________________________________________________________________________________________
How did the accident or exposure occur? (Describe fully the events that resulted in injury or occupational disease. Tell what happened
and how it happened.) _____________________________________________________________________________________
_______________________________________________________________________________________________________
Object or substance that directly injured employee? (e.g. the machine employee struck against or which struck him/her; the vapor or
poison inhaled or swallowed; chemical that irritated his/her skin. In cases of strains, the thing(s) he/she was lifting, pulling, etc.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
No
Names of eyewitnesses: __________________________________________ Witness Statement Attached:
Yes
Employee Signature: ____________________________________________ Date: _____________________________________
Supervisor’s Work Address: _________________________________ Supervisor's Work Phone: __________________________
Supervisor’s Statement: ____________________________________________________________________________________
_______________________________________________________________________________________________________
Supervisor’s Signature: _____________________________________ Date: __________________________________________
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Parent category: Business