Accident Reporting Form "*" indicates required fields Form Initiator* First Last Submission Date* MM slash DD slash YYYY Supervisor's Name* First Last Supervisor's Work Email* Supervisor's Business Phone #* Involved Employee's Information Involved Employee* First Last Employee #*Primary Language*Job #*Union* Yes No Employee's Department*Job Title*Employee's Typical Job Duties Accident Report Details Date of Accident* MM slash DD slash YYYY Time of Accident*Date Accident was Reported* MM slash DD slash YYYY Time Accident was Reported*How was the Supervisor Aware/Notified of Accident?* Witnessed Accident In Person By Telephone Other Please Explain*Reported By* First Last Telephone #* Injury Report Section Exact Location/Area where Accident Occurred*Nature of Injury (strain, cut, or bruise)*Body Parts Affected (Be Specific: left hand, or right ankle)*Medical Treatment* None Required Refused First Aid/Medical Care (complete refusal) On-Site First Aid Urgent Care Emergency Room Hospital Physician Other Did Employee Leave Work Due to Injury?* Yes No Time Left*Transportation* Walked Private Vehicle Ambulance Company Vehicle Unknown Accident as Described by the Involved Employee*Additional Comments and Notes Workers' compensation fraud statement: Any person who knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any false material statement or conceals any material fact, shall be guilty of a crime and subject to substantial fines and imprisonment. My signature affirms that the information that I am providing is true and accurate to the best ofmy knowledge and belief. I understand that this information may be used to make a claim under the New York State Worker's Compensation Law. I am fully aware that filing a false or misleading Workers' Compensation claim is a crime punishable by law. Signature* Δ
