Incident Report Form
All accidents and near-misses, regardless of extent, should be reported promptly by filling out this form completely and submitting (be sure to click "Continue" at the bottom of this page and verify & submit on the next page).

If the injured person is an employee (Faculty, Staff or Student Employee) and the injury is work-related, the "NYU Work Related incident/Injury Form" must also be completed and submitted by the employee's supervisor or HR Representative. The NYU form can be found here: http://www.nyu.edu/employees/resources-and-services/financelink/insurance-and-risk/available-coverage/workers-compensation.html
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Date/Time of Incident:
Example: 03/05/2016 11:30 AM
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Time
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Type of Incident
Incident Involved
Name of Person(s) Involved:
Include phone number & if they are a student, faculty, staff or other.
Was an employee (includes faculty, staff & student employees) injured while working?
If Yes, a Supervisor or HR Representative must complete the NYU Work Related Injury - Incident Form to submit a Worker's Comp claim: http://www.nyu.edu/employees/resources-and-services/financelink/insurance-and-risk/available-coverage/workers-compensation.html
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Description of Injury or Incident
For injury, describe type of injury and affected body part(s).
How did the injury or incident occur?
What was person doing? What machines, materials, or chemicals were involved? Were there problems with the physical space (e.g. floor not level, liquid on the floor, equipment in the way)?
Did the injured person receive first aid or medical treatment?
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Who was supervising at the time of the incident/injury?
Comments or Action Taken
Injured received first aid, went to Student Health Services, etc.
What measures are being taken to prevent reoccurrence of a similar incident?
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