Employee Accident/injury/illness Report Form - Cohoes City School District printable pdf download

Cohoes City School District

Employee Accident/Injury/Illness Report Form

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.

Physician/Health Care Professional Information:

This

Injury and Illness Incident Report is one of the first forms you

must fill out when a recordable work-related injury or illness has occurred.

6) Name of physician or other health care professional _______________

Together with the Log of Work-Related Injuries and Illnesses and the

accompanying Summary, these forms help the employer and PESH develop a

__________________________________________________________

picture of the extent and severity of work-related incidents.

7) If treatment was given away from the worksite, where was it given?

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

Facility__________________________________________________

equivalent. Some state worker’s compensation, insurance, or other reports may be

acceptable substitutes. To be considered an equivalent form, any substitute must

Street ___________________________________________________

contain all the information asked for on this form.

City _____________________________ State _____ Zip _________

According to 12 NYCRR Part 801, PESH recordkeeping rule, you

must keep this form on file for 5 years following the year to which it pertains. If

8) Was employee treated in an emergency room?

you need additional copies of this form, you may photocopy and use as many as

Yes

you need.

9) Was employee hospitalized overnight?

Completed by _____________________________________________

Yes

Title _____________________________________________________

Phone (______) ______-_________ Date _____/_____/_____

Information about the case:

Employee Information:

10) Case number from the Log _______________________

(Transfer the case number from the Log after you record the case.)

1) Full name ________________________________________________

The Business Office will input the log number.

2) Street ___________________________________________________

11) Date of injury or illness _____/_____/_____

City _____________________________ State _____ Zip __________

12) Time employee began work ______________ AM / PM

3) Date of birth _____/_____/_____ 4) Date hired _____/_____/_____

13) Time of event ______________ AM / PM

Male

Female

14) What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was

using. Be specific. Examples: “ climbing a ladder while carrying roofing materials” ; “ spraying chlorine from 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 and how it was affected; be more specific that “ hurt ” , “ pain” , or “ sore.”

Examples: “ strained back”; “ chemical burn, hand.”

17) What object or substance directly harmed the employee? Examples: “ concrete floor” ; “ radial arm saw”; “chlorine.”

18) If the employee died, when did death occur? Date of death ______/______/______

ILLNESS CASES ONLY 9 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 (6-02)