Fillable Employee Accident & Investigation Report Form (Page 2 of 2) in pdf

Directions for Completing this Form

Item 01 Employee’s name, as it appears on payroll stub and his/her Negotiating Unit (e.g. OSU).

Item 02 Employee’s current mailing address.

Item 03 Employee’s Social Security number, as it appears on the employee’s payroll stub. Employee’s current

home telephone number.

Item 04 Employee’s date of birth. Indicate employee’s sex by checking male or female.

Item 05 Employee’s job title and normal work location.

Item 06 Employee’s normal shift, i.e., days, evenings or nights (specify hours); the days the employee is

normally off duty. Indicate whether the employee works full or part-time.

Item 07 Employee’s campus address and phone number.

Item 08 The date the employee was hired.

Item 09 The date and time the employee was injured.

Item 10 The building and floor, unit, or other information to indicate where the accident occurred.

Item 11 Indicate exactly what the injury is and what body part(s) have been affected (e.g., sprain to right ankle,

cut to the left forearm, cuts to knees of both legs).

Item 12 This item must be checked after determining whether or not the employee was able to remain at the

normal work station. If known, please indicate whether or not the injured employee has returned to

work and, if the employee has returned to work, indicate their date of return. Item 13 Check to

determine whether employee required medical attention either immediately after the accident or at

some subsequent date. If unknown, check NO. If yes, indicate the name and address of the doctor and/

or hospital.

Item 14 Identify the tools, equipment or material that the employee was using and what he/she was actually

doing at the time of the injury/illness. Please be specific.

Item 15 Fully describe the events that resulted in the injury or exposure. Specifically explain what happened and

how it happened. Particular objects, unsafe conditions, or other factors contributing to the illness or

injury should be mentioned.

Item 16 Indicate the machine or tool that caused the injury; the vapor or substance inhaled or swallowed; the

chemical that irritated the employee’s skin. In cases of strains, the object(s) the employee was lifting,

pulling, etc.

Item 17 Employee’s signature and date employee completed the form. If the employee is unable or unavailable

to sign, please leave blank.

Item 18 Names of eyewitnesses who were present and saw the accident occur, with their description of what

happened.

Item 19 The assigned supervisor should describe any condition that may exist or any other relevant information

concerning the accident.

Item 20 Supervisor’s signature and date the supervisor completes the report.

Item 21 Supervisor’s campus work location and telephone number.

Attention: This form contains information relating to employee health and must be used in a manner that

protects the confidentiality of employees to the extent possible while the information is being used for

occupational safety and health purposes.

Any person who knowingly with intent to defraud makes a

materially false statement or conceals a material fact to obtain a benefit, shall be guilty of crime.

Reports suspected of Workers Compensation fraud will be sent to the Workers Compensation Fraud

Inspector General of Albany, NY

Employee Accident & Investigation Report Form Page 2