NYU Work Related Incident / Injury Form

This form is to be filled out by Supervisors or Human Resource Representatives ONLY! 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.

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"

NYU Work Related Incident / Injury Form

Personal Information

University ID Number:
Social Security Number:
Employee Name (First, Middle, Last):
Date of Birth (MM/DD/YYYY):
Sex: Male Female
Marital Status: Single Married Divorced Widowed

Home Address (Include No. & Street, City, State, Zip & Apt. No.):


County:
Home Phone Number (xxx-xxx-xxxx):

Work Information

Campus: New York University NYU Poly
Normal Work Shift Starting Time (Please indicate AM or PM):
Normal Work Shift Ending Time (Please indicate AM or PM):
Was Employee Paid in Full for Injury Date?: Yes No

Employment Status:

Name of Supervisor (First & Last Name):
Supervisor Phone Number (xxx-xxx-xxxx):

Occupation (Specific job title at which employed):

Employee Work Address:

Department:

Employee Object Code:

Work Phone Number (xxx-xxx-xxxx):

Date of Hire (MM/DD/YYYY):

Employee Emergency Contact Information

Emergency Contact Name:

Relationship to Employee:

Emergency Contact Address (Include No. & Street, City, State, Zip & Apt. No.)


Emergency Contact Home Phone Number (xxx-xxx-xxxx):

Emergency Contact Work Phone Number (xxx-xxx-xxxx):

Wage Information

Hourly Rate:
Hours Per Day:
Wage Per Day:
Days Per Week:

Wage Per Week:

Union:

Employees Work Week (Choose all that apply):
Monday Tuesday Wednesday Thursday Friday
Saturday Sunday

Payroll Schedule: Weekly Biweekly Monthly Semi-monthly

Dependent Information

Number of Dependents:

Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:
Name: Birth Date: Relationship:

Injury Data

Date of Accident (MM/DD/YYYY):
Time of Accident (Please indicate AM or PM):

When was Employer Notified of Accident? (Date & Time):


Exact Location of Accident
(e.g. Mailroom, Loading Dock, etc.):

NYU Address Where Incident Occurred:

If Incident did not occur on NYU Property, Please Select "NO NYU ADDRESS" above,
and enter Full Address Below.
(Street Address, State, Zip Code):

What was the Object or Substance that Directly Caused the Injury?:


List any known Witness(es), their Phone Number(s)
and their affiliation (co-worker, passerby, student, faculty, etc.):
(Example: John Smith / (212) 555-1234 / co-worker.)
If None, indicate "none" below.

Specific Body Part:

Side:

Name and Address of Doctor:


Was Employee Taken to a Medical Facility?: Yes No

If Employee was taken to a Medical Facility,
Please Indicate the Name and Address:


What was the Employee Doing When Injured?
(Please be specific. Identify tools, equipment or material the employee was using):


How did the Accident or Exposure Occur? (Please be as specific as possible):


When was the Last Day the Employee Worked?:

Has Employee Returned to Work?: Yes No
If Employee has Returned to Work, What was the Date? (MM/DD/YYYY):
If Employee has NOT Returned to Work,
What is the Expected Return to Work Date? (MM/DD/YYYY):

Loss Prevention

Identify any Safety Policies or Procedures Not Followed
Which May Have Helped Cause the Incident?:


What Measures, if any, Have Been Taken or are Planned to be Taken
to Prevent Recurrence of a Similar Incident?:


Miscellaneous Questions

Was Protection Department Notified?: Yes No

Was First Aid / Medical Care Provided by NYU Staff?: Yes No

Total Number of Accumulated Sick Days (Before Accident):
If the above number is zero, please type "zero" and do not enter "0".

Name, Title and Phone Number of Who Filled Out This Form:
(Example: John Smith / Supervisor / 212-555-5678)


Email Address of Person Who Filled Out This Form:

Was Employee Working or Off-Duty at the Time of the Accident?:
On-Duty Off-Duty

Supervisor Comment Box:


Name and Phone Number of Human Resources Representative:
(Example: John Smith / 212-555-9056)


Email Address of Human Resources Representative:

Print Form Before Submission

Please use a Large Capacity / High Speed printer to print this document.
The spooling time required to print this on a small desktop printer, will take 5 to 10 minutes!
Even when using the High Speed printer, it will take between 30 seconds and 1 minute to process.
Please be Patient.

Print me!

Form Submission

To create a paper copy of this form, push the "Print Me!" button above, BEFORE you push the "SUBMIT" button below. REMEMBER to send a copy of this form to the employees Human Resources Representative. As part of the Insurance Departments standard procedure, we will be sending you a confirmation of your submitted report, but all confidential items will be removed from the distributed copy.