Get Northeastern University Worker's Compensation Accident/illness/near Miss Report Form 2018

Filling out the Northeastern University Worker's Compensation Accident/Illness/Near Miss Report Form online is essential for reporting any work-related injuries, illnesses, or near misses. This guide will provide you with clear, step-by-step instructions to ensure the completion of the form is accurate and efficient.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing Part A, which should be done by the injured worker or supervisor immediately after the accident. Fill in all required fields, including the employee's name, ID, date of birth, and contact information. Be sure to detail the incident and any prior treatments for similar conditions.
3. Proceed to indicate the body parts injured and the hours worked within the 48-hour period preceding the incident. Ensure that the employee's signature is provided alongside the date.
4. Next, the supervisor must complete Part B. This includes confirming any medical treatment received by the injured worker, describing the injury, and detailing any conditions that may have led to the incident.
5. Gather any witness information and confirm whether the injured worker has lost time from work. The supervisor should include their signature, printed name, and contact extension.
6. Don’t forget to sign the attached Medical Records Release Authorization. This authorization is necessary for the evaluation of the claim.
7. Once all parts are completed, ensure the form is sent to the Office of Risk Services via email or physical address, retaining copies for the department records and the employee.
8. Submit the completed form within 24 hours of the incident. If any information is missing, it can be submitted later.
9. After submission, save any changes made to the form, download it for your records, print a copy if needed, or share it as required.

Ensure you file the Northeastern University Worker's Compensation Report Form online promptly to facilitate a smooth claims process.