Instructions for completing an Accident/Injury/Illness Report Form

Please complete all fields in full.  This information will be used to establish your claim with our carrier if there is lost time or medical treatment beyond first aid.  

• Please use your full legal name and full address. 
• When describing the accident/injury/illness, be specific. Be sure to specifically designate all body parts affected, for example left leg, right foot, left side of neck, etc.
• When describing how the injury occurred- be specific. 
• The form will be automatically routed to your supervisor based on your building location, from there it is forwarded on to Human Resources.
• If you lose time from the injury, you must supply a doctor’s note taking you out of work.  The note must specify the reason for the absence, the approximate duration of the absence or the date of your next follow up. 
• If treatment is obtained or if you have additional questions, you must provide documentation of all information regarding the treatment and notify HR immediately.  HR contact number: Kathleen King (Instructional) at 315-638-6047 or Beth Evanchak (Non Instructional) at 315-638-6049