On The Job Accident And Injury Report printable pdf download

On The Job Accident And Injury Report

ON-THE-JOB ACCIDENT AND INJURY REPORT

PART 1: To be completed by the employee (also see Part 3)

Employee’s Name (PRINT): ______________________________________________________________________________

Address:____________________________________________

Home Telephone:____________________________

____________________________________________

Date of Birth: _______________________________

Title:

____________________________________________

Bargaining Unit: _____________________________

Time shift began: ___________________________________

Pass Days: _____________ Line #: _____________

Date of Employment: __________________________________

Gender: _____________Male _____________Female

Date of Accident: ____________________________________

Time of Accident:____________________________

Place of Accident:_____________________________________

Did employee remain on duty? Yes _____ No _____

NYS ARS Incident Number (see part 3) ______________________________________________________________

Was medical care provided?

Yes _____ No _____

If yes, give name and address of physician and/or hospital:

Was treatment provided in an emergency room? ____Yes ____No Was employee hospitalized overnight? ____Yes ____No

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. Attach additional page, if necessary.

What happened? Tell how the injury occurred. Attach additional page, if necessary.

What was the injury or illness? Tell what part of the body that was affected and how it was affected; be more specific than hurt,

pain, or sore. Include right or left to indicate exact location.

What object or substance directly harmed the employee? Examples: concrete floor, radial arm, saw, chlorine.

Employee Signature ____________________________________________________ Date ____________________________

On-the-Job Accident and Injury Report, Page 1 of 2: Rev 1/2009

On The Job Accident And Injury Report