Northeastern University Worker's Compensation Accident/Illness/Near Miss Report Form 2019-2025 free printable template
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NORTHEASTERN UNIVERSITY
WORKERS COMPENSATION ACCIDENT/ILLNESS/NEAR MISS
REPORT FORM
(For reporting work related injuries/illnesses)InstructionsPart A is to be completed by the employee or supervisor
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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
Begin by downloading the Northeastern University Worker's Compensation Accident/Illness/Near Miss Report form from the university's website.
02
Fill out the date of the incident at the top of the form.
03
Provide your name, job title, and department where the accident or illness occurred.
04
Describe the circumstances of the incident in detail, including what happened, how it happened, and any contributing factors.
05
Include information about any witnesses, including their names and contact details.
06
Specify the type of injury or illness sustained, including body parts affected.
07
Indicate whether medical attention was sought and provide the details of the healthcare provider if applicable.
08
Sign and date the report to verify the information is accurate.
09
Submit the completed form to your supervisor and retain a copy for your records.
Who needs Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
01
Any employee of Northeastern University who experiences a work-related injury, illness, or near miss is required to complete this report.
02
Supervisors and managers who need to document workplace incidents for safety and compliance purposes.
03
Human resources personnel who handle worker's compensation claims and related investigations.
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What is Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
It is a report used to document any accidents, illnesses, or near misses that occur in the workplace at Northeastern University.
Who is required to file Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
All employees who experience a work-related accident, illness, or near miss incident are required to file this report.
How to fill out Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
To fill out the report, an employee should provide detailed information regarding the incident, including the date, time, location, a description of the event, and any injuries sustained.
What is the purpose of Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
The purpose of the report is to ensure the proper documentation of workplace incidents for the safety of employees, compliance with regulations, and to facilitate appropriate compensation processes.
What information must be reported on Northeastern University Worker's Compensation Accident/Illness/Near Miss Report?
The report must include the employee's name, job title, details of the incident, description of injuries, witnesses, and any corrective actions taken.
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