Employee Accident/injury/illness Report Form - Cohoes City School District Page 2

Supervisor’s Accident/Injury Report

Accident on premises? YES G or NO G

Date supervisor first knew of injury:

Was employee paid in full for the day? YES G or NO G

IF LOSS OF WORK TIME OR MEDICAL BILLS HAVE BEEN INCURRED, SUPERVISOR MUST COMPLETE THE FOLLOWING

Supervisor’s investigation:

Has employee returned to work: YES G or NO G

Date employee stopped work:

If yes, on what date did employee return to work?

Did employee sign the Medical/Wage consent form? YES G or NO G

Signature of Supervisor

Date

Report of Witness to Injury

(state exactly what you witnessed)

___________________________________________________________________________________________________________

__________________________________________________________________________________________________________

FATAL CASES:

Date of Death:

Name & address of nearest relative:

This form must be completed within 48 hrs of the accident; upon completion forward to Administration Center.

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Parent category: Business