Form Sh-900 - Log Of Work Related Injuries And Illnesses - New York State Department Of Labor

Download a blank fillable Form Sh-900 - Log Of Work Related Injuries And Illnesses - New York State Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Sh-900 - Log Of Work Related Injuries And Illnesses - New York State Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Print Form
Political Subdivision (Employer)
New York State
Establishment Name
Department of Labor
Calendar Year 20 ____
Street Address
Log of Work Related Injuries and Illnesses Form
Page ____of ____
City
State
Zip Code
SH-900
work activity or job transfer, days away from work, or medical treatment beyond first aid. You
1.
This form is required by the Commissioner of Labor’s Rules and Regulations
4.
This form contains information relating to employee health and must be used in
Part 801 (12 NYCRR Part 801) and must be kept in the establishment for five
must also record significant work-related injuries and illnesses that are diagnosed by a
a manner that protects the confidentiality of employees to the extent possible
years. Failure to maintain this form can result in the issuance of a Notice of
physician or licensed health care professional. You must also record work-related injures and
while the information is being used for occupational safety and health
Violation and Order to Comply.
illnesses that meet any of the specific recording criteria found in 12 NYCRR 801.7 - 801.12 and
purposes. Refer to the instructions (SH-901) for types of illness and injuries
2.
You must record information about every work-related death and about every
instructions.
defined as privacy concern cases.
work-related injury or illness that involves loss of consciousness, restricted
3.
Use more than one line for a single case if necessary.
M. Check the Injury Column
or Check One Type of Illness
Using these categores, check
Enter No. of
ONLY the most serious result
Days Injured or
for each case.
Ill Worker Was:
Remained at Work
F. Describe injury or illness, parts of body affected, and
D. Date of
E. Where the Event
object/substance that directly injured or made person ill
Injury or Onset
H. Days
L. On Job
I. Job Transfer
J. Other
K. Away from
of Ilness
Occurred (e.g., Loading
(e.g., Second degree burns on right forearm from
Away From
Transfer or
or Restriction
Recordable
Work
A.Case No.
B. Employee Name
C. Job Title
dock, north end)
acetylene torch)
(Mo./day)
G. Death
Work
restriction
Cases
Additional forms and information: If you require additional forms or information concerning the completion of this form, contact: Department of Labor,
Division of Research and Statistics, 75 Varick St., 7th Floor, New York, NY 10013. Telephone (212) 775-3344.
TOTALS
SH 900 (1-08)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go