RFHR Accident Report Form

Employee's Name

First NameLast Name

Employee's Email Address

example@example.com

Are you submitting this on behalf of the Employee indicated above?

Your Name

First NameLast Name

Your Email Address

example@example.com

Note: If you are completing this form on behalf of an employee and certain employee information is unavailable, you may enter “N/A” in the application fields or skip them.

Employee's Address

Street Address

Street Address Line 2

CityState

Zip Code

RF Employee ID #

Home Phone

Please enter valid phone numberFormat: (000) 000-0000.

Department

Date of Birth

MonthDayYear

Gender

Date of Hire

MonthDayYear

Job Title

Regular Daily Work Hours

Enter your daily start and end time

Job Type

Physical Work Location

Campus Phone

Please enter valid phone numberFormat: (000) 000-0000.

Date and Time of Accident

MonthDayYear

Hour MinutesAM/PM Option

Date

MonthDayYear

Time

Hour Minutes

AM/PM Option

Place of Accident

Enter name of building and/or address

Nature of injury

Part(s) of body affected

Did the employee remain on duty?

Returned to work?

If yes, please indicate return date

MonthDayYear

Supervisor's Name

First NameLast Name

Supervisor's Email

example@example.com

Did the employee require medical attention?

If yes, when?

MonthDayYear

Was the employee admitted to the hospital for in-patient treatment (formally admitted overnight)?

Name of Medical Provider

Name and Address of Medical Facility

What was the employee doing when injured?

Be specific, identify tools, equipment, or material the employee was using

How did the accident or exposure occur?

Describe fully the events that resulted in injury or occupational disease. Tell what happened and how it happened

What was the object or substance that directly injured the employee?

E.g. the machine employee struck against or which struck him/her; the vapor or poison inhaled or swallowed; chemical that irritated his/her skin, etc. In cases of strains, the thing(s) he/she was lifting, puling, etc

Acknowledgement

Date of Acknowledgment

MonthDayYear

Are there any eyewitnesses?

How many eyewitnesses were there?

Enter number, e.g. 1. Maximum number of 3.

Eyewitness's Name

First NameLast Name

Eyewitness Email

example@example.com

Eyewitness's Comment

2nd Eyewitness's Name

First NameLast Name

2nd Eyewitness's Email

example@example.com

2nd Eyewitness's Comment

3rd Eyewitness's Name

First NameLast Name

3rd Eyewitness's Email

example@example.com

3rd Eyewitness's Comment

Date accident first reported to Supervisor

MonthDayYear

Supervisor Comment

Enter any details such as factual observations, immediate actins taken, contributing factors, employees account and preventative measures, and how you were informed of the accident (email, in-person, etc.).

Supervisor Acknowledgment

Date of Acknowledgment

MonthDayYear

Supervisor's Campus Address

Supervisor's Campus Phone

Please enter the valid phone numberFormat: (000) 000-0000.

If you have any questions, please contact rfhr@albany.edu or call (518) 437-4500.

Did this accident result in the employee's death?

Was the employee admitted to the hospital for in-patient treatment (formally admitted overnight)?

Did the employee experience an amputation (loss of limb or digit)?

Did the employee experience the loss of an eye?

Note: If yes to any of the above, call OSHA’s confidential number at 1-800-321-OSHA; call the closest area OSHA office during normal business hours; or using the online form within 24 hours of the accident.

Research Foundation Human Resources

Supervisor Statement

RFHR Office