Work-Related Employee Injury/illness Incident Report For State Employees Page 3
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3NOTE: This report 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.
Any employee who files a false report will be subject to the appropriate administrative action including disciplinary action
pursuant to the applicable collective bargaining unit.
EMPLOYEE INSTRUCTIONS:
1. Report your injury or illness to your direct supervisor or their designee immediately.
2. Get medical attention if needed. Report to the University Hospital Emergency Department (ED) during off hours or in
a life-threatening emergency, and inform them that your injury is work-related.
3. The employee, employee’s supervisor, University Hospital Emergency Department (ED) and/or your private medical
provider are responsible for completing their section(s) of this report. If you have not received medical attention at this
time, this must be noted on the report. NOTE: If medical attention is sought at a later date, documentation must be
provided from your private medical provider to Human Resource Services, Time and Attendance z=0751. Human
Resource Services, Time and Attendance will notify Environmental Health and Safety (EH&S), z=6200 for
OSHA/PESH recordkeeping purposes.
4. The employee must call the NYS Accident Reporting System (ARS) at 888-800-0029 to report the incident and
receive an ARS incident number. The ARS incident number must be added to the report.
5. All occupational injuries or illnesses that occur to employees while on duty must be promptly reported by the
employee to fulfill legal reporting requirements under the NYS Workers’ Compensation Laws, the Occupational
Safety and Health Administration (OSHA), and the Public Employee Safety and Health Bureau (PESH).
6. Complete this report within 24 hours after a work-related injury or illness. Return the completed report to your
supervisor or designee for proper distribution.
7. Supervisors are required to perform an investigation of the injury or illness to determine the root cause(s) and their
corrective action(s) to be taken to prevent the incident from being repeated. This information must be provided in the
Supervisors Statement section of the report.
8. The Employee Injury/Illness Incident Report must be completed in its entirety and signed legibly.
9. If the employee was exposed to a hazardous material or a bloodborne pathogen (BBP) the employee must be
evaluated by the Department of Occupational and Environmental Medicine or the University Hospital Emergency
Department (ED); however, the employee is not required to accept treatment. If the injury involves a BBP they must
be evaluated within 2 hours of the injury.
10. Notify your direct supervisor or their designee and Human Resources Services, Time and Attendance if your private
medical provider extends the off-duty time beyond the time authorized by the Department of Occupational and
Environmental Medicine or the University Hospital Emergency Department (ED).
11. If subsequent medical attention is received, documentation must be provided from your private medical provider to
Human Resources Services, Time and Attendance. The note from your private medical provider should contain a
diagnosis code, prognosis, and estimated date of return.
Important: Promptly completing all of the above steps for reporting your work related injury/illness will ensure payment of
all your compensable medical bills and lost work time. In order for the New York State Insurance Fund to evaluate your
case for payment of your Workers’ Compensation wage replacement benefits and medical bills they need to have a copy
of your injury/illness report from your employer, ARS notification, and a medical report from a physician indicating your
disability is due to your job-related injury.
Distribution:
Human Resources Services, Time and Attendance, 390 Administration Bldg. z=0751
Environmental Health & Safety, 110 Suffolk Hall z=6200
SUSB3019 (08/10)
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