Get Northeastern University Worker's Compensation Accident/illness/near Miss Report Form 2015

Completing the Northeastern University Worker's Compensation Accident/Illness/Near Miss Report Form is essential for reporting any work-related injuries, illnesses, or near misses. This guide provides clear, step-by-step instructions to ensure you can successfully fill out the form online.

Follow the steps to complete the report form accurately.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling out Part A, labeled 'Injured worker’s statement of accident/illness.' You should provide your full name, employee ID, date of birth, home address, and contact numbers. Also, fill in the date and time of the incident, where it occurred, and include a detailed description of the accident.
3. Indicate if you have previously been treated for a similar condition. If you answered yes, provide additional details. Make sure to specify which body parts were injured, indicating right or left as necessary.
4. Sign and date Part A, confirming the accuracy of the statements made.
5. Next, the supervisor must complete Part B. This section requires details about the medical treatment received, including the name and address of any medical facility involved. The supervisor should also describe the injury and any preventive measures that could have been taken to avoid the incident.
6. The supervisor must document any witnesses and indicate whether the injured worker lost time from work. If applicable, the date of the first full day of disability should be noted, along with details of when the injured worker returned to work.
7. Both the supervisor and the injured worker should sign and date their respective parts of the form.
8. Finally, ensure that the Medical Records Release Authorization is signed by the injured worker. Once all parts of the form are complete, send a copy to the designated email or the Office of Risk Services.
9. Retain a copy of the completed form for your records, and remember to submit the form within 24 hours of the incident.

Complete the Northeastern University Worker's Compensation Accident/Illness Report Form online today to ensure a swift reporting process.