EMPLOYEE'S WORKPLACE INJURY/ILLNESS REPORT FORM

EMPLOYEE'S WORKPLACE INJURY/ILLNESS REPORT FORM

Complete this form within 24 hours of a workplace injury/illness

If you have questions, please contact Human Resources at hr_benefit@fitnyc.edu

Employee FIT ID Number*

Employee Last Name*

Employee First Name*

Employee Address*

Please include apt. number, if applicable

Employee City, State, Zip

Employee Phone Number*

Phone

Employee FIT Email Address*

Employee Job Title*

Employee Department*

Select

Employee Work Schedule*

Incident Date*

Incident Time*

Reported to Security?*

Yes

Incident Location (Bldg., Room, Offsite Location)*

Time you reported to work on the incident day*

First Day of Absence

Last Day of Absence

Side*

Right Side

Left Side

Both

What were you doing when injured? Be specific.*

How did the injury occured?*

What object or substance directly harmed you? *

Action taken to prevent incident reoccurence

Name and contact information of any witnesses

Medical treatment provided*

Physician or hospital contact information

Name, address and phone of physician or hospital

Supervisor Name*

Supervisor Email*

Employee Acknowledgment*

Upon completion, a Workers' Compensation (WC) claim may be initiated with FIT's WC carrier, PMA. PMA will assign a case manager who will work with you if this injury requires medical care.

If you did not miss any time from work or don't require medical care, the claim will simply serve as a record of your workplace injury in case you need associated medical care or miss work in the future.

If you missed time from work due to this injury, please submit your absences here.

For more information on FIT's Workers' Compensation policy, please visit the Workers' Compensation Program.

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