INCIDENT / INJURY REPORT FORM
ALL ACCIDENTS AND NEAR-MISSES, REGARDLESS OF EXTENT, SHOULD BE REPORTED PROMPTLY BY FILLING OUT THIS FORM COMPLETELY AND SUBMITTING TO THE SAFETY SPECIALIST.
IF INJURED IS AN EMPLOYEE (Faculty, Staff, Student Employee) AND THE INJURY IS WORK-RELATED,
the “NYU Work Related Incident/Injury Form” MUST ALSO BE COMPLETED AND SUBMITTED BY THE SUPERVISOR
NAME OF INJURED:
NYU ID#:
ADDRESS OF INJURED:
☐FACULTY
☐STAFF
☐STUDENT ☐GUEST
IF STUDENT, IS STUDENT A STUDENT EMPLOYEE? ☐YES ☐NO
WAS STUDENT WORKING AT TIME OF INJURY? ☐YES ☐NO
INJURED PARTY IS:
DATE OF INCIDENT:
TIME OF INCIDENT:
LOCATION OF INCIDENT:
DESCRIPTION OF INJURY OR INCIDENT :
HOW DID THE INJURY OR INCIDENT OCCUR (WHAT WAS INJURED DOING; WHAT MACHINES OR
MATERIALS OR CHEMICALS WERE INVOLVED)?
WHAT STEPS WERE TAKEN AFTER THE INCIDENT OCCURRED (FIRST AID, STUDENT HEALTH
SERVICES, PUBLIC SAFETY, 911, ETC)?
FRONT / BACK
RIGHT / LEFT
PLEASE MARK THE INJURED AREA
ON THE ABOVE DIAGRAMS
DID THE INJURED PERSON REFUSE TREATMENT?
☐YES ☐NO
WHO WAS SUPERVISING AT THE TIME OF INJURY?
ADDITIONAL COMMENTS / WHAT MEASURES ARE BEING TAKEN TO PREVENT REOCCURANCE OF A SIMILAR INCIDENT?
PERSON COMPLETING THIS FORM:
NAME:
EMAIL:
DATE:
PHONE:
Send form to Randy Susevich, Safety Specialist - email: [email protected]; fax: 5-3474
For office use only—cc to:
__Student Affairs
__Faculty Affairs
__HR
__Admin & Finance __Other
Rev 2014-11-14