NEW YORK STATE - DEPARTMENT OF LABOR
INJURY AND ILLNESS INCIDENT REPORT
FORM SH 900.2
Attention: This form contains information relating to employee health and must be used in a manner that protects the
confidentiality of employees to the extent possible while the information is being used for occupational safety and health
purposes.
This Injury and Illness Incident Report is one of the first forms you must fill out
when a recordable work-related injury or illness has occurred. Together with
the
Log of Work Related Injuries and Illnesses and the accompanying Summary,
these forms help the employer and PESH develop a picture of the extent and
severity of work-related incidents.
Within 7 calendar days after you receive information that a recordable work-
related injury or illness has occurred, you must fill out this form or an
equivalent.
Some state workers' compensation, insurance, or other reports may be
acceptable substitutes. To be considered an equivalent form, any substitute
must contain all the information asked for on this form.
According to 12NYCRR Part 801, PESH recordkeeping rule, you must keep
this form on file for 5 years following the year to which it pertains.
If you need additional copies of this form, you may photocopy and use as
many as you need.
Completed by _______________________________________
Title _______________________________________________
Phone
( )______________________Date _____/_____/_____
Employee Information:
1) Full name _______________________________________________
2) Street __________________________________________________
City ________________________ State _____ Zip ________________
3) Date of birth _____/_____/_____ 4) Date hired _____/_____/_____
5)
Male Female
14) What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material
the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from
hand sprayer."
15) What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet", "Worker
was sprayed with chlorine when gasket broke during replacement."
16) What was the injury or illness? Tell us the part of the body that was affected; be more specific than "hurt", "pain", or "sore."
Examples: "strained back", "chemical burn, hand."
17) What object or substance directly harmed the employee: Examples: "concrete floor", "radial arm saw", "chlorine."
18) If the employee died, when did death occur? Date of death _____/_____/_____
ILLNESS CASES ONLY Check this box if the employee independently and voluntarily requests that his or her name
not be entered on the log. If checked, treat as a privacy concern case.
SH-900.2 (1-05)
Physician/Health Care Professional Information:
6) Name of physician or other health care professional
__________________________________________________
7) If treatment was given away from the worksite, where was it
given?
__________________________________________ ______
Facility _________________________________________
Street
City _____________________ State _____ Zip ________
8) Was employee treated in an emergency room?
Yes No
9) Was employee hospitalized overnight?
Yes No
Information about the case:
10) Case number from the Log _________________________
(Transfer the case number from the Log after you
record the case.)
11) Date of injury or illness
______/______/_____
12) Time employee began work ______________ AM / PM
13) Time of event
______________ AM / PM
Check if time cannot be determined
Event occurred before during after
work shift
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