Fillable Employee Accident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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Employee Accident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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BROWSE STATE UNIVERSITY OF NEW YORK COLLEGE OF AGRICULTURE AND TECHNOLOGY AT COBLESKILL FORMS

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Quick Facts for Workers’ Compensation
• If an employee becomes injured on the job
o Employee must report the incident to their supervisor
o Employee must complete an accident report- signed by the supervisor and submit form
to Donna Magill ASAP.
o Donna Magill (in Human Resources) MUST be notified- magilldl@cobleskill.edu; 518-
255-5412
o Employee must call ARS to report injury 1-888-800-0029
o If necessary, employee should go to the emergency department, urgent care, or
schedule an appointment with their primary care provider.
§ Tell the provider you are seeking treatment under Workers’ Compensation
• If an employee seeks medical treatment
o A doctor’s note needs to be provided to supervisor and Donna Magill in Human
Resources
§ The note must state
• Date of treatment
• Medical restrictions, if any
• Length of time out of work, if any
• If an employee is taken out of work
o Employee must follow normal time-off procedures and charge the first 5 days of time
off, if applicable.
o Employee must remain in contact with supervisor and Donna Magill in Human
Resources
o Employee must provide a return to work note stating capacity in which he/she may
return, and if any restrictions. If the accommodations can be met the employee may be
able to return to work.
SUNY COBLESKILL
EMPLOYEE ACCIDENT REPORT
CAREFULLY FOLLOW DIRECTIONS ON BACK:
1. EMPLOYEE NAME
BARGAINING UNIT
2. EMPLOYEE’S ADDRESS
HOME PHONE NUMBER
4. DATE OF BIRTH
SEX
Male Female
5. JOB TITLE
DEPARTMENT
6. Work Schedule on
date of accident
PASS DAYS
(ex. Sat/Sun)
Full Time Part Time
7. EMPLOYEE’S WORK LOCATION (Campus Address)
CAMPUS PHONE
8. HOW LONG EMPLOYED (Date Employee was Hired)
9. DATE OF ACCIDENT
TIME OF ACCIDENT
10. PLACE OF ACCIDENT
11. NATURE OF INJURY AND PART(S) OF BODY AFFECTED
HAS THIS BODY PART BEEN INJURED BEFORE?
YES NO
IF YES, WHEN?
12. EMPLOYEE REMAINED ON DUTY?
YES NO
Contact Payroll if out of work, 255-5412
HAS EMPLOYEE RETURNED TO WORK?
YES NO*
IF YES, DATE OF RETURN
*Notify Payroll at 255-5412 immediately when employee returns to work
13. EMPLOYEE REQUIRED MEDICAL ATTENTION?
YES NO*
IF YES, WHEN?
NAME AND ADDRESS OF DOCTOR
NAME AND ADDRESS OF HOSPITAL
*If employee later seeks medical attention, contact Payroll at 255-5412 and provide medical documentation.
14. WHAT WAS EMPLOYEE DOING WHEN INJURED? (BE SPECIFIC; identify tools, equipment or material the employee was using)
15. HOW DID ACCIDENT OR EXPOSURE OCCUR? (Describe fully the events that resulted in injury or occupational disease. Tell what happened and how it
happened.)
16. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE (e.g. the machine employee struck against or which struck him/her; the vapor or poison
inhaled or swallowed; chemical that irritated his/her skin. In cases of strains, the thing(s) he/she was lifting, pulling, etc.)
DATE
18. NAMES OF EYEWITNESSES WITH STATEMENT(S)
19. SUPERVISOR’S STATEMENT (Include date Supervisor first knew of injury.)
20. SUPERVISOR’S SIGNATURE
DATE
22. SUPERVISOR’S NAME (PRINT)
21. CAMPUS ADDRESS
CAMPUS PHONE
You MUST call 1-888-800-0029 TO REPORT ALL accidents.
Incident #_________________ (provided when you call in)
Send original to Payroll, Knapp Hall 123 or fax: 255-5657
Send copy to Environmental Health & Safety, Facility Management
Department/Individual retain copy for your records
click to sign
signature
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SUNY COBLESKILL
EMPLOYEE ACCIDENT REPORT
Directions for Completing EAR Part 1: Employee Accident and Investigation Report
Item 1
Employee’s name, as it appears on payroll stub and his/her Negotiating Unit (e.g. OSU).
Item 2
Employee’s current mailing address.
Item 3
Employee’s Social Security number, as it appears on the employee’s payroll stub.
Employee’s current home telephone number.
Item 4
Employee’s date of birth. Indicate employee’s sex by checking male or female.
Item 5
Employee’s job title and normal work location.
Item 6
Employee’s normal shift, i.e., days, evenings or nights (specify hours); the days the employee is normally off duty.
Indicate whether the employee works full or part-time.
Item 7
Employee’s campus address and phone number.
Item 8
The date the employee was hired.
Item 9
The date and time the employee was injured.
Item 10
The building and floor, unit, or other information to indicate where the accident occurred.
Item 11
Indicate exactly what the injury is and what body part(s) have been affected (e.g., sprain to right ankle, cut to the left
forearm, cuts to knees of both legs).
Item 12
This item must be checked after determining whether or not the employee was able to remain at the normal work station.
If the employee loses work time as a direct result of this injury or illness, please contact Payroll 255-5412 to indicate the
expected duration of the absence. If known, please indicate whether or not the injured employee has returned to work
and, if the employee has returned to work, indicate their date of return.
Item 13
Check to determine whether employee required medical attention either immediately after the accident or at some
subsequent date. If unknown, check NO. If yes, indicate the name and address of the doctor and/or hospital.
Item 14
Identify the tools, equipment or material that the employee was using and what he/she was actually doing at the time of
the injury/illness. Please be specific.
Item 15
Fully describe the events that resulted in the injury or exposure. Specifically explain what happened and how it happened.
Particular objects, unsafe conditions, or other factors contributing to the illness or injury should be mentioned.
Item 16
Indicate the machine or tool that caused the injury; the vapor or substance inhaled or swallowed; the chemical that
irritated the employee’s skin. In cases of strains, the object(s) the employee was lifting, pulling, etc.
Item 17
Employee’s signature and date employee completed the form. If the employee is unable or unavailable to sign, please
leave blank.
Item 18
Names of eyewitnesses who were present and saw the accident occur, with their description of what happened.
Item 19
The assigned supervisor should describe any condition that may exist or any other relevant information concerning the
accident.
Item 20
Supervisor’s signature and date the supervisor completes the report.
Item 21
Supervisor’s campus work location and telephone number.
Item 22
Supervisor’s current home telephone number.
PLEASE CALL WORKERS’ COMPENSATION AT 1-888-800-0029 TO REPORT THE INCIDENT.
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Employee Accident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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Completed 26 July 2020

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