Get Northeastern University Worker's Compensation Accident/illness/near Miss Report Form 2019-2025

Filling out the Northeastern University Worker's Compensation Accident/Illness/Near Miss Report Form online is essential for documenting any work-related incidents. This guide provides you with clear, step-by-step instructions to ensure that the form is completed accurately and promptly.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully read and fill out Part A, which must be completed by the employee or supervisor immediately after any on-the-job accident or near miss. Ensure to answer all questions, provide the employee’s name, ID, date of birth, home address, and preferred contact details.
3. Document the date, time of occurrence, and the location of the incident accurately. In the description field, provide a detailed account of the accident, incident, or near miss. If additional space is required, attach a separate sheet.
4. If applicable, answer questions related to any injuries, including previous similar conditions and treatment details.
5. Obtain the required signature of the employee upon completion of Part A and fill in the date completed.
6. Next, proceed to Part B for the supervisor's statement. Discuss the event in detail with the employee before completing this section.
7. In Part B, provide information on whether the employee received medical treatment and, if transferred to a hospital, specify which hospital.
8. Include a detailed description of the incident, weather conditions at the time, and any necessary evaluations of equipment involved in the incident.
9. Indicate whether the employee lost time from work and when they returned, as well as gather the names and contact information of any witnesses.
10. Ensure that the supervisor provides their signature, completes the date, and includes their printed name along with their phone extension.
11. If the injured employee needs to sign the attached Medical Records Release Authorization, make sure that is completed as well.
12. Finally, save your changes, and download, print, or share the completed form as necessary. Send the completed form to insurance@northeastern.edu or the Office of Risk Services. Remember to keep a copy for both the employee and department records.

Complete your forms online promptly to ensure thorough and accurate reporting.