Get Stony Brook University Susb3019 2012

The Stony Brook University SUSB3019 form is essential for reporting work-related injuries and illnesses among employees. This guide is designed to help you navigate the process of filling out the form online efficiently and accurately.

Follow the steps to complete the SUSB3019 form online.

1. Press the ‘Get Form’ button to access the SUSB3019 document and open it in your preferred online editor.
2. Begin by completing Section 1, which requires employee information. Fill in your last name, first name, home phone, home address, date of birth, gender, employee's SSN, ARS incident number, job title, employee ID number, date of hire, department, work phone, worker’s compensation case/file number, and work shift.
3. In Section 2, provide detailed injury or illness information. Enter the date, time, location, and specifics of the injury or illness. Indicate if medical attention was sought, whether the employee remained on duty, and provide dates for when the employee stopped work and returned to duty. Describe the activity just before the incident, how the injury occurred, and specify the nature of the injury.
4. If applicable, check the box for illness cases where the employee requests confidentiality regarding their identity on the injury/illness log. Include their printed name, signature, and date.
5. Moving to Section 3, record medical information. Identify the type and nature of the injury, the medical treatment provided, and whether a prescription was prescribed. Note the body part affected and the location where treatment occurred, including any hospitalization details if relevant.
6. In Section 4, if there are witnesses, include their statements and names. The supervisor should also confirm incident details and corrective actions taken to prevent recurrence.
7. Once all sections are complete, review the form carefully for accuracy. You may save changes or download the completed document. Finally, ensure it is signed appropriately.
8. Submit the form as required to your supervisor or designated party for proper distribution.

Complete the Stony Brook University SUSB3019 form online today to ensure your work-related injury or illness is reported accurately.