Injury/Illness Report (MS Word) - Buffalo State College
Buffalo State
Employee Personal Injury/Illness Form
Instructions: Complete Parts I and II and sign and forward to Human Resource Management, CLEV 410. Please contact the Accident Reporting System (ARS) at 1-888-800-0029 toll free, 24 hours a day, every day, to report the incident. If you have any questions, please contact the Payroll Office at 878-4124 or Human Resource Management at 878-4821.
|PART I - PERSONAL INFORMATION |
| | |
|Name: |Department: |
| | |
|Home Address: |Supervisor: |
| | |
|Home Phone: |Occupation: |
| | |
|Campus Address / Phone Number: |Date of Hire: |
| | | |
|Negotiating Unit: |Pass Days: |Salary: |
|PART II - INCIDENT INFORMATION |
| | |
|Accident Date and Time: |Witnesses: |
| | |
|Location of Accident: |Medical Treatment Provided: (check if applicable) |
|(building, room no., parking lot no.) | |
| |First Aid by Staff Hospital Personal Physician |
| | |
|Part of body injured: |Name, Address & Telephone Number of Doctor/Hospital: |
| | |
| | |
|Type of injury: |Has employee returned to work? Yes No |
| |If yes, date and time: |
|(e.g. bruise, burn, cut, fracture, puncture, swelling, sprain, strain, etc.) | |
| |
|Description of incident: (Include causal factors that contributed to the accident. Please be specific and include as many details as possible. Attach |
|additional sheets if necessary.) |
| |
| |
|NYS ARS Incident #: | |
| | |
|Report Completed by: |Date: |
| |
|Any person who knowingly with intent to defraud makes a materially false statement, or conceals a material fact to obtain a benefit, shall be guilty of a crime |
|and subject to fines and imprisonment. Reports suspected of workers' compensation fraud will be sent to the Workers' Compensation Fraud Inspector General in |
|Albany, NY. |
| | |
|Employee Signature: |Date: |
|HRM/Payroll use only |
| |
|Process C-2 if medical treatment received and or Lost Time |
C: Supervisor
Environmental Health & Safety Office
Revised 5/2017
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