NYU Work Related Incident / Injury Form
Please fill out as completely as possible before submitting to the Insurance Department!
This form is to be filled out by Supervisors or
Human Resource Representatives ONLY!
Attention Supervisors:
Notify your Human Resources Representative of all work related incidents and injuries.
Print a copy of this form and forward it to the employees Human Resources Representative BEFORE you push the "Submit" button. You must continue to report all LOST TIME information to the employees Human Resources Representative.
Employees should not use this form to submit Workers' Compensation claims. You must notify your supervisor immediately of any work related incident, injury or illness.
GENERAL INSTRUCTIONS:
Use the TAB key or MOUSE click to move from field to field.
CAUTION: Using the ENTER key will automatically submit the form.
PLEASE REVIEW YOUR SUBMISSION BEFORE CLICKING "SUBMIT"
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New York University
Insurance & Risk Management Department
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