Form Sh 900.2 - Injury And Illness Incident Report
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1NEW YORK STATE - DEPARTMENT OF LABOR
INJURY AND ILLNESS INCIDENT REPORT
FORM SH 900.2
This form contains information relating to employee health and must be used in a manner that protects the
Attention:
confidentiality of employees to the extent possible while the information is being used for occupational safety and health
purposes.
This
is one of the first forms you must fill out
Injury and Illness Incident Report
Physician/Health Care Professional Information:
when a recordable work-related injury or illness has occurred. Together with
6) Name of physician or other health care professional
the
__________________________________________________
Log of Work Related Injuries and Illnesses and the accompanying Summary,
7) If treatment was given away from the worksite, where was it
these forms help the employer and PESH develop a picture of the extent and
given?
severity of work-related incidents.
__________________________________________ ______
Within 7 calendar days after you receive information that a recordable work-
related injury
or illness has occurred, you must fill out this form or an
equivalent.
Some state workers' compensation, insurance, or other reports may be
Facility
_________________________________________
acceptable substitutes. To be considered an equivalent form, any substitute
Street
must contain all the information asked for on this form.
City _____________________ State _____ Zip ________
8) Was employee treated in an emergency room?
According to 12NYCRR Part 801, PESH recordkeeping rule, you must keep
this form on file for 5 years following the year to which it pertains.
If you need additional copies of this form, you may photocopy and use as
Yes
No
many as you need.
9) Was employee hospitalized overnight?
Completed by _______________________________________
Yes
No
Information about the case:
Title _______________________________________________
10) Case number from the Log
_________________________
Phone
(
)______________________Date _____/_____/_____
(Transfer the case number from the Log after you
record the case.)
Employee Information:
______/______/_____
11) Date of injury or illness
12) Time employee began work ______________
AM /
PM
_______________________________________________
1)
Full
name
__________________________________________________
2) Street
13) Time of event
______________
AM /
PM
________________________
City
State _____ Zip ________________
_____/_____/_____
_____/_____/_____
3) Date of birth
4) Date hired
Check
if
time
cannot
be
determined
5)
Event occurred
before
during
after
work shift
Male
Female
14)
What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material
Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from
the employee was using. Be specific.
hand sprayer."
15) What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet", "Worker
was sprayed with chlorine when gasket broke during replacement."
16) What was the injury or illness? Tell us the part of the body that was affected; be more specific than "hurt", "pain", or "sore."
Examples: "strained back", "chemical burn, hand."
17)
Examples: "concrete floor", "radial arm saw", "chlorine."
What object or substance directly harmed the employee:
18) If the employee died, when did death occur? Date of death _____/_____/_____
ILLNESS CASES ONLY
Check this box if the employee independently and voluntarily requests that his or her name
not be entered on the log. If checked, treat as a privacy concern case.
SH-900.2 (1-05)
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