"Employee Notification of Workplace Accident" - Town of Clayton, New York

Employee Notification of Workplace Accident is a legal document that was released by the Finance Department - Town of Clayton, New York - a government authority operating within New York. The form may be used strictly within Town of Clayton.

Form Details:

  • The latest edition currently provided by the Finance Department - Town of Clayton, New York;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Finance Department - Town of Clayton, New York.

ADVERTISEMENT
ADVERTISEMENT

Download "Employee Notification of Workplace Accident" - Town of Clayton, New York

Download PDF

Fill PDF online

Rate (4.7 / 5) 6 votes
Page background image
Employee Notification of Workplace Accident
To be completed immediately after a workplace accident for workers’ compensation benefits
Employee Information
To be completed by the employee.
ID:
Last Name:
First Name:
Best phone number to reach you:
Employee Affiliation/Type:
Administrative
Buildings & Grounds
Did you tell your supervisor of the injury/illness? Yes
No
If so, when? _______________
Highway
Department:
Job Title:
Seasonal: Marina
Seasonal: Pool
Name of
Supervisor:
Seasonal: Other
Supervisor Contact Phone No. (if known):
Volunteer
Accident Information
Please answer all questions
Date of injury/illness
(mm/dd/yyyy): __________
Time you started work:
Time of injury/illness:
AM
PM
AM
PM
Location (building name, room, etc.) where injury/illness occurred:
How did the incident occur / what task were you engaged in at the time injury/illness began?
Nature of Injury
Body Part
Type of Injury
Please Select:
Please Select:
Please Select:
Bite/ Scratch
Abrasion
Abdomen
Bodily Reaction
Animal Bite or Scratch
Ankle
Caught in/ Under/ BTN
Burn
Elbow
Chemical Spill
Contact w/ Chemical
Disc (Back)
Chemical Exposure
Contact w/ Electrical
Fingers
Extreme Temperature
Contusion
Foot
Fall from Elevation
Crushed
Groin
Fall on the Same Level
Foreign Body
Head
Motor Vehicle
Fracture
Knee
Needle Stick
Illness/ Infection
Lower Back
Overexertion
Laceration
Multiple Body Parts
Puncture
Needle Stick
Neck Injury
Puncture
Rubbed/ Abraded
No Physical Injury
Rash
Slip/Trip
Pelvis
Struck Against
Repetitive Motion
Right Side
Left Side
Struck By
Sprain/ Strain
Other (describe below)
Struck By/ Against
Exposure
Other (specify below)
Description (if not
If Exposure, Select Type:
above):
Car Accident? Yes
No
Dermal (Skin)
Description (if not
Injection
above):
Inhalation
Ingestion
If other, please describe:
If the accident was caused by
a needle, please list the type
of needle (device brand/type):
If you need help filling out this form, please ask your supervisor or human resources
Employee Notification of Workplace Accident
To be completed immediately after a workplace accident for workers’ compensation benefits
Employee Information
To be completed by the employee.
ID:
Last Name:
First Name:
Best phone number to reach you:
Employee Affiliation/Type:
Administrative
Buildings & Grounds
Did you tell your supervisor of the injury/illness? Yes
No
If so, when? _______________
Highway
Department:
Job Title:
Seasonal: Marina
Seasonal: Pool
Name of
Supervisor:
Seasonal: Other
Supervisor Contact Phone No. (if known):
Volunteer
Accident Information
Please answer all questions
Date of injury/illness
(mm/dd/yyyy): __________
Time you started work:
Time of injury/illness:
AM
PM
AM
PM
Location (building name, room, etc.) where injury/illness occurred:
How did the incident occur / what task were you engaged in at the time injury/illness began?
Nature of Injury
Body Part
Type of Injury
Please Select:
Please Select:
Please Select:
Bite/ Scratch
Abrasion
Abdomen
Bodily Reaction
Animal Bite or Scratch
Ankle
Caught in/ Under/ BTN
Burn
Elbow
Chemical Spill
Contact w/ Chemical
Disc (Back)
Chemical Exposure
Contact w/ Electrical
Fingers
Extreme Temperature
Contusion
Foot
Fall from Elevation
Crushed
Groin
Fall on the Same Level
Foreign Body
Head
Motor Vehicle
Fracture
Knee
Needle Stick
Illness/ Infection
Lower Back
Overexertion
Laceration
Multiple Body Parts
Puncture
Needle Stick
Neck Injury
Puncture
Rubbed/ Abraded
No Physical Injury
Rash
Slip/Trip
Pelvis
Struck Against
Repetitive Motion
Right Side
Left Side
Struck By
Sprain/ Strain
Other (describe below)
Struck By/ Against
Exposure
Other (specify below)
Description (if not
If Exposure, Select Type:
above):
Car Accident? Yes
No
Dermal (Skin)
Description (if not
Injection
above):
Inhalation
Ingestion
If other, please describe:
If the accident was caused by
a needle, please list the type
of needle (device brand/type):
If you need help filling out this form, please ask your supervisor or human resources
Were you seen in an emergency room? Yes
No
Were you hospitalized overnight as an inpatient? Yes
No
No
What object directly harmed you?
Were you in contact with blood or bodily fluids? Yes
No
Were you harmed by a sharp object?
Yes
To whom did you report the accident? (Name):
Date reported (mm/dd/yyyy):
Time reported: ______________
Witness name (if known):
Witness’ email:
Witness' phone:
Signature
I CERTIFY THAT THE ACCIDENT INFORMATION PROVIDED ABOVE IS TRUE.
Completed by Employee
Completed by Employer
If completed by employer, state your name and relationship to the employee:
Date (mm/dd/yyyy):
Signature:
Submitting Your Accident Report
This form is only complete after it has been submitted to either your HR Departmental contact or your supervisor.
Please submit this form by scanning and sending it to
support@townofclayton.com.
Received by HR:
Date: ______________ Initials: _____________
Injured Worker Packet to Employee: ☐
Forward to Report and C-2F to NCA Comp: ☐
Page of 2