Doc. No. & Rev.
EHS-00083 R2
Hard copy of this document, if not marked “CONTROLLED” in red,
is by definition uncontrolled and may be out of date.
Specification
for
OSHA ACCIDENT REPORTING
REVISION
Rev
No.
2
DCN No.
Change Summary
Release
Date
DCN Initiator
DCN1239
Added new contact information and revised
for clarity
9-11-15
D. Greenlee
Document
Owner
T. Diamond
Prior revision history, if applicable, is available from the Document Control Office.
CNSE Confidential
Created by CNSE on September 7, 2015
Page 1 of 8
OSHA Accident Reporting
EHS-00083 R2
1
PURPOSE
1.1
To provide specific guidelines for the reporting of a work related injury or
illness to OSHA, when necessary.
2
SCOPE
2.1
This specification applies to all employees, contractors and
subcontractors at SUNY Polytechnic Institute’s Colleges of Nanoscale
Science and Engineering (CNSE) who could be part to or witness to an
incident.
3
DEFINITIONS
3.1
Accident- Accidents are unplanned incidents that may involve injuries or
illnesses to any employees, regardless of employer, or students.
3.2
Injury or Illness- An injury or illness is an abnormal condition or disorder.
Injuries include cases such as, but not limited to, a cut, fracture, sprain, or
amputation. Illnesses include both acute and chronic illnesses, such as,
but not limited to, a skin disease, respiratory disorder, or poisoning.
NOTE: Injuries and illnesses are recordable to OSHA only if they
are new, work-related cases that meet one or more of the Part
1904 recording criteria.
3.3
OSHA- Occupational Safety and Health Administration (OSHA) is an
agency of the United States Department of Labor. Congress established
the agency under the Occupational Safety and Health Act. OSHA's
mission is to "assure safe and healthful working conditions for working
men and women by setting and enforcing standards and by providing
training, outreach, education, and assistance”.
3.4
Work-Related- an event or exposure in the work environment either
caused or contributed to the resulting condition or significantly aggravated
a pre-existing injury or illness. Work-relatedness is presumed for injuries
and illnesses resulting from events or exposures occurring in the work
environment unless an exception in 1904.5(b)(2) specifically applies
(Appendix B).
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OSHA Accident Reporting
4
EHS-00083 R2
ASSOCIATED DOCUMENTS
EHS-00083-F1 - OSHA Incident Reporting Form
5
DISTRIBUTION
5.1
Copies of this Reporting Guideline with the Appendices will be maintained
at this facility in the following locations:

EHS Offices

Emergency Response Team office

Security Control Center
6
PROCEDURE
6.1
Internal Reporting Procedure
6.1.1
Any workplace injury or incident occurring on the CNSE Fuller Road
campus which requires medical treatment shall be reported by calling
Security at 437-8600.
6.1.2
While responding to the incident the ERT or Security Officer shall
determine if the injury meets one or more of the criteria listed in Section
5.2. If yes, the ERT or Security Officer shall contact one of the following
people, as soon as possible (i.e. within one hour), in order, until one of
them is reached:
Role
Primary Contact
Name
Tom Diamond,
VP EHS
1st Alternate Contact
Dan Greenlee
2nd Alternate Contact
Contact Information
Cell: 518-441-6850
Home: 845-331-2391
Cell: 518-545-6376
Home: 845-297-5179
Brenda Streeter
Cell: 518-414-2628
rd
Lilia Chen
Cell: 518-795-4689
th
Kassey Brust
Cell: 518-380-1847
3 Alternate Contact
4 Alternate Contact
6.2
External Reporting Requirements
6.2.1
The employer of the affected employee is responsible for reporting its
applicable incidents to OSHA.
6.2.2
All work-related fatalities must be reported to OSHA within 8 hours.
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OSHA Accident Reporting
EHS-00083 R2
6.2.3
All work-related in-patient hospitalization, amputation, or loss of an eye,
must be reported to OSHA only if these occur within 24 hours of the workrelated incident. Employers must report the event internally within 24
hours of learning about it.
6.2.4
Fatalities occurring within 30 days of a work-related incident must be
reported to OSHA.
6.2.5
In-patient hospitalization or fatality due to a heart attack must be reported
if the heart attack resulted from a work-related incident.
6.2.6
External Reporting for CNSE will be performed by the following
individuals:
Name
Tom Diamond, VP EHS
Dan Greenlee
Contact Information
Cell: 518-441-6850
Home: 845-331-2391
Cell: 518-545-6376
Home: 845-297-5179
Brenda Streeter
Cell: 518-414-2628
Lilia Chen
Cell: 518-795-4689
Kassey Brust
Cell: 518-380-1847
NOTE: Tenants or contractor companies shall do the external reporting to
OSHA for its own employees.
6.3
Verbal Notification Requirements
6.3.1
The OSHA Incident Reporting Form (EHS-00083-F1, see Appendix A for
sample) can be used to collect appropriate information prior to calling
OSHA.
6.3.2
The following information is required to be reported to OSHA

Establishment name

Location of incident

Time of incident

Number of fatalities or hospitalized employees

Names of any injured employees

Contact person and phone number
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OSHA Accident Reporting

6.3.3
EHS-00083 R2
Brief description of the incident
Notification to OSHA can be made by one of the following methods:
Method
OSHA’s free and confidential number
Number/Location
1-800-321-OSHA (6742)
Area Office nearest to the site of the
incident during normal business hours
ONLY
(518) 464-4338 (Albany)
Online Form
when available
7
APPENDICES
7.1
Appendix A – OSHA Incident Reporting Form – Sample (EHS-00083-F1)
7.2
Appendix B – Table 1904.5(b)(2) Situations Where Recording and
Reporting is Not Required
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OSHA Accident Reporting
EHS-00083 R2
APPENDIX A - OSHA Incident Reporting Form – Sample
(see EHS-00083-F1)
INFORMATION ABOUT THE EMPLOYEE
1)
Full Name
2)
Date of birth
3)
Date of injury or illness
4)
Male
Female
5)
/
/
/
/
If treatment was given away from the worksite, where was it given? For example:
Facility: Albany Medical Center
Street: 43 New Scotland Avenue
City:
Albany
State: NY
Zip:
6)
Was employee taken to the emergency room?
Yes
No
7)
Was employee hospitalized?
Yes
No
8)
Time employee began work
9)
Time of event
12208
AM/PM
AM/PM
Check if time cannot be determined
10) 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"; "daily computer key-entry."
11) 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"; "Worker developed soreness in wrist over time."
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OSHA Accident Reporting
EHS-00083 R2
12) What was the injury or illness? Tell us the part of the body that was affected and
how it was affected; be more specific than "hurt", "pain", or "sore." Examples: "strained
back"; "chemical burn, hand"; "carpal tunnel syndrome."
13) What object or substance directly harmed the employee? Examples: "concrete
floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it
blank.
14) If the employee died, when and where did death occur? Date of death?
/
Examples of the location are CNSE or Albany Medical Center.
/
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.
Completed by:
Title:
Phone:
Date:
EHS person reported to:
Time Reported to EHS:
AM
PM
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OSHA Accident Reporting
EHS-00083 R2
APPENDIX B - Situations Where Recording and Reporting is Not
Required
1904.5(b)(2)
You are NOT required to record injuries and illnesses if . . .
(i)
At the time of the injury or illness, the employee was present in the
work environment as a member of the general public rather than as an
employee.
(ii)
The injury or illness involves signs or symptoms that surface at work
but result solely from a non-work-related event or exposure that occurs
outside the work environment.
(iii)
The injury or illness results solely from voluntary participation in a
wellness program or in a medical, fitness, or recreational activity such
as blood donation, physical examination, flu shot, exercise class,
racquetball, or baseball.
(iv)
The injury or illness is solely the result of an employee eating, drinking,
or preparing food or drink for personal consumption (whether bought
on the employer's premises or brought in). For example, if the
employee is injured by choking on a sandwich while in the employer's
establishment, the case would not be considered work-related.
NOTE: If the employee is made ill by ingesting food contaminated by
workplace contaminants (such as lead), or gets food poisoning from
food supplied by the employer, the case would be considered workrelated.
(v)
The injury or illness is solely the result of an employee doing personal
tasks (unrelated to their employment) at the establishment outside of
the employee's assigned working hours.
(vi)
The injury or illness is solely the result of personal grooming, selfmedication for a non-work-related condition, or is intentionally selfinflicted.
(vii)
The injury or illness is caused by a motor vehicle accident and occurs
on a company parking lot or company access road while the employee
is commuting to or from work.
(viii)
The illness is the common cold or flu (NOTE: contagious diseases
such as tuberculosis, brucellosis, hepatitis A, or plague are considered
work-related if the employee is infected at work).
(ix)
The illness is a mental illness. Mental illness will not be considered
work-related unless the employee voluntarily provides the employer
with an opinion from a physician or other licensed health care
professional with appropriate training and experience (psychiatrist,
psychologist, psychiatric nurse practitioner, etc.) stating that the
employee has a mental illness that is work-related.
Source: www.osha.gov
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