Northeastern University Worker's Compensation Accident/Illness/Near Miss Report Form 2018 free printable template
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NORTHEASTERN UNIVERSITY
WORKERS COMPENSATION ACCIDENT/ILLNESS REPORT FORM
(for reporting work related injuries/illnesses)InstructionsPart A is to be completed by the injured worker or supervisor immediately
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How to fill out Norformastern University Workers Compensation AccidentIllnessNear Miss
How to fill out Northeastern University Worker's Compensation Accident/Illness/Near Miss Report
01
Obtain a copy of the Northeastern University Worker’s Compensation Accident/Illness/Near Miss Report form from your supervisor or the HR department.
02
Fill in the employee's personal information including name, employee ID, department, and contact details.
03
Describe the incident or illness in detail, including the date, time, and location where it occurred.
04
Provide a clear and concise explanation of what happened, including any contributing factors.
05
Include witness information if there were any witnesses to the incident.
06
Indicate whether medical attention was sought and provide details of the medical provider if applicable.
07
Sign and date the form, certifying that the information provided is complete and accurate.
08
Submit the completed form to your supervisor or directly to the HR department as per your department’s protocol.
Who needs Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
01
Any employee who has experienced a work-related injury, illness, or near miss incident.
02
Supervisors needing to document incidents for workplace safety purposes.
03
Human Resources personnel for processing worker's compensation claims.
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What is Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
The Northeastern University Worker's Compensation Accident/Illness/Near Miss Report is a formal document used to report any work-related accidents, illnesses, or near misses occurring within the university. It serves to document the incident and initiate the workers' compensation process.
Who is required to file Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
Any employee of Northeastern University who experiences a work-related accident, illness, or near miss is required to file the report. Additionally, supervisors or managers should file reports for incidents involving their employees.
How to fill out Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
To fill out the report, an employee must provide specific details about the incident, including the date, time, location, nature of the injury or illness, witnesses, and any immediate actions taken. The form must be completed as soon as possible following the incident.
What is the purpose of Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
The purpose of the report is to document incidents for safety compliance, identify potential hazards, facilitate the workers' compensation process, and promote a safer work environment by analyzing the cause of the incidents.
What information must be reported on Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
The report must include the employee's information, details of the incident (date, time, location), a description of the injury or illness, corrective actions taken, names of any witnesses, and any other relevant documentation that supports the claim.
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