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State of New York Workers Compensation BoardC2FEmployer's First Report of Correlated Injury/Illness work related injury or illness must be reported within 10 days (Per Section 110) of the injury/illness

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How to fill out work-related injuryillness

01

Gather all necessary information about the work-related injury or illness.

02

Complete the employee information section, including name, contact information, and job title.

03

Provide details about the date, time, and location of the incident.

04

Describe the nature of the injury or illness in a clear and concise manner.

05

Include any witnesses or individuals who were present when the incident occurred.

06

Indicate whether medical treatment was sought and provide relevant details.

07

If applicable, include information about any medical professionals involved in the treatment.

08

Specify any work restrictions or accommodations needed as a result of the injury or illness.

09

Review the completed form for accuracy and completeness.

10

Submit the filled-out work-related injury/illness form to the appropriate supervisor or HR department.

Who needs work-related injuryillness?

01

Employees who have experienced a work-related injury or illness need to fill out a work-related injury/illness form.

02

Employers and supervisors also require this information to comply with legal and workplace safety obligations.

03

Insurance companies and healthcare providers may also require this form to process claims or provide appropriate treatment.

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What is work-related injury/illness?

Work-related injury/illness is any injury or illness that occurs as a result of performing job duties.

Who is required to file work-related injury/illness?

Employers are required to file work-related injury/illness reports for their employees.

How to fill out work-related injury/illness?

Work-related injury/illness reports can be filled out electronically or on paper forms provided by the relevant authorities.

What is the purpose of work-related injury/illness?

The purpose of work-related injury/illness reports is to document and track workplace injuries and illnesses to ensure proper care and prevention strategies are in place.

What information must be reported on work-related injury/illness?

Information such as the date, time, location, description of the incident, and the injured or ill employee's details must be reported on work-related injury/illness reports.

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