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.