Work-Related Employee Injury/illness Incident Report For State Employees
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1
2
3EH&S USE ONLY
Recordable
Non-Recordable
Case # _____________________________________
Main Campus
Work-Related
Stony Brook Southampton
Employee Injury/Illness Incident Report
For State Employees
Attention:
This form contains information relating to employee health and MUST be used in a manner that protects the confidentiality of employees.
SECTION 1. EMPLOYEE INFORMATION: TO BE COMPLETED BY EMPLOYEE AND/OR SUPERVISOR
Last name: ____________________________________ First name: _______________________ Home phone: _________________
Home address: ___________________________________________________City: ________________State:_______ Zip: ________
Date of birth: ____________ Gender:
Male
Female Employee’s SSN: ______________ ARS incident #: _______________
Job title: ___________________________________________ Employee’s ID # __________________ Date of hire: ______________
Employee’s department: __________________________________________________________ Work phone: __________________
Worker’s compensation case/file #: ___________________________
Employee’s work shift: _____________________
AM
PM
SECTION 2. INJURY/ILLNESS INFORMATION: TO BE COMPLETED BY EMPLOYEE AND/OR SUPERVISOR
Date of injury or illness: __________________
Time of injury or illness: ____________
AM
PM
Location of injury or illness
: _____________________________________________________________________________
(bldg/area)
Specific location of injury or illness
(room, stairwell, etc.): ________________________________________________________________________
Did the employee seek medical attention?
Yes
No
Did the employee remain on duty?
Yes
No
Date employee stopped work because of this injury or illness: _______________ Date employee returned to duty: ________________
What was the employee doing JUST BEFORE the accident?
Describe the activity, as well as the tools, equipment, or materials the employee
was using. Be specific. (Examples “I was standing on a ladder and reaching to repair a leaking valve on a water pipe”).
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
What happened?
Tell us how the injury occurred. (Example;”The ladder slipped on wet floor and I fell to the floor 20 feet below landing on my right
_______________________________________________________________________________________________________
side”).
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
What was the injury or illness?
Tell us the part of the body that was affected and the nature of the injury/illness (how it was affected); be more
specific than “hurt”, “pain”, or “sore” (Example: “Contusion to right shoulder, elbow and knee).
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Check this box if the employee independently and voluntarily requests that his or her name NOT be entered on
Illness Cases Only
the injury/illness log. If this box is checked, treat as a privacy concern case.
Name (Print): ________________________________________ Signature: ______________________________ Date: ____________
SUSB3019 (08/10)
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Parent category: Business