Get NY SH-900 2008-2024

Telephone 212 775-3344. SH 900 1-08 TOTALS Enter No. of Days Injured or Ill Worker Was M. Check the Injury Column or Check One Type of Illness Remained at Work G. Death H. Skin Dis Political Subdivision Employer Establishment Name Street Address City 1. Inju ry New York State Department of Labor Log of Work Related Injuries and Illnesses Form SH-900. Refer to the instructions SH-901 for types of illness and injuries defined as privacy concern cases. Using these categores check ONLY the most serious result for each case. A. Case No. B. Employee Name C. Job Title D. Date of Injury or Onset of Ilness Mo. /day E. Where the Event Occurred e.g. Loading dock north end F. Describe injury or illness parts of body affected and object/substance that directly injured or made person ill e.g. Second degree burns on right forearm from acetylene torch Additional forms and information If you require additional forms or information concerning the completion of this form contact Department of Labor Division of Research and Statistics 75 Varick St. 7th Floor New York NY 10013. Print Form Page of Zip Code 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. Refer to the instructions SH-901 for types of illness and injuries defined as privacy concern cases. Using these categores check ONLY the most serious result for each case. A. Case No* B. Employee Name C. Job Title D. Date of Injury or Onset of Ilness Mo. /day E* Where the Event Occurred e*g* Loading dock north end F* Describe injury or illness parts of body affected and object/substance that directly injured or made person ill e*g* Second degree burns on right forearm from acetylene torch Additional forms and information If you require additional forms or information concerning the completion of this form contact Department of Labor Division of Research and Statistics 75 Varick St* 7th Floor New York NY 10013. Days Away From Work I. Job Transfer or Restriction J* Other Recordable Cases K. Away from L* On Job Transfer or 5. Hea ring Lo ss 6. All O the Illnesse r s 4. Pois oning work activity or job transfer days away from work or medical treatment beyond first aid* You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional* You must also record work-related injures and illnesses that meet any of the specific recording criteria found in 12 NYCRR 801. 7 - 801. 12 and instructions. 3. Use more than one line for a single case if necessary. order State 3. Res pirato Conditio ry n This form is required by the Commissioner of Labor s Rules and Regulations Part 801 12 NYCRR Part 801 and must be kept in the establishment for five years. Failure to maintain this form can result in the issuance of a Notice of Violation and Order to Comply. You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness restricted Calendar Year 20 2. .