ACCIDENT AND INJURY REPORTING

In the event of an emergency, call 333 from a campus phone or (631) 632-3333 a non-campus phone.

This includes:

• Fires
• Explosions
• Large hazardous material spills
• Serious injuries (e.g., death, amputation, concussion, crushing, fracture, burn, laceration with serious bleeding or requiring stitches, or hospitalization)
• Laboratory-acquired infections
• Exposures to hazardous materials, including biohazardous material
• Incidents that have the potential to cause serious injury or harm

The following forms must be used to report accidents involving an injury, illness or exposure to chemical, biological or radiological materials (via inhalation, splash or other accident):

• State:  State Employee Injury/Illness Report 
• RF:  Research Foundation Work-Related Employee Injury/Illness Incident Report 
• Minors/Students:  Student Accident/Injury Report 
• Hospital Employees:  Stony Brook Medicine Injury/Illness Report

1. Report your injury or illness to your direct supervisor or their designee immediately.
2. Get medical attention if needed. Report to the University Hospital Emergency Department (ED) during off hours or in a life-threatening emergency, and inform them that your injury is work-related.
3. The employee, employee’s supervisor, University Hospital Emergency Department (ED) and/or your private medical provider are responsible for completing their section(s) of this report. If you have not received medical attention at this time, this must be noted on the report. NOTE: If medical attention is sought at a later date, documentation must be provided from your private medical provider to Human Resource Services, Time and Attendance z=0751. Human Resource Services, Time and Attendance will notify Environmental Health & Safety (EH&S), z=6200 for OSHA/PESH recordkeeping purposes.
4. The employee must call the NYS Accident Reporting System (ARS) at (888) 800-0029 to report the incident and receive an ARS incident number. The ARS incident number must be added to the report.
5. All occupational injuries or illnesses that occur to employees while on duty must be promptly reported by the employee to fulfill legal reporting requirements under the NYS Workers’ Compensation Laws, the Occupational Safety and Health Administration (OSHA), and the Public Employee Safety and Health Bureau (PESH).
6. Complete the State Employee Injury/Illness report within 24 hours after a work-related injury or illness. Return the completed report to your supervisor or designee for proper distribution.
7. Supervisors are required to perform an investigation of the injury or illness to determine the root cause(s) and their corrective action(s) to be taken to prevent the incident from being repeated. This information must be provided in the 'Supervisors Statement' section of the report.
8. The State Employee Injury/Illness Incident Report must be completed in its entirety and signed legibly.
9. If the employee was exposed to a hazardous material or a bloodborne pathogen (BBP) the employee must be evaluated by the Department of Occupational and Environmental Medicine or the University Hospital Emergency Department (ED); however, the employee is not required to accept treatment. If the injury involves a BBP they must be evaluated within 2 hours of the injury.
10. Notify your direct supervisor or their designee and Human Resources Services, Time and Attendance, if your private medical provider extends the off-duty time beyond the time authorized by the Department of Occupational and Environmental Medicine or the University Hospital Emergency Department (ED).
11. If subsequent medical attention is received, documentation must be provided from your private medical provider to Human Resources Services, Time and Attendance. The note from your private medical provider should contain a diagnosis code, prognosis, and estimated date of return.

Important: Promptly completing all of the above steps for reporting your work related injury/illness will ensure payment of all your compensable medical bills and lost work time. In order for the New York State Insurance Fund to evaluate your case for payment of your Workers’ Compensation wage replacement benefits and medical bills they need to have a copy of your injury/illness report from your employer, ARS notification, and a medical report from a physician indicating your disability is due to your job-related injury.

1. Report your injury or illness to your direct supervisor or their designee immediately.
2. Get medical attention if needed. Report to the University Hospital Emergency Department (ED) during off hours or in a life-threatening emergency, and inform them that your injury is work-related.
3. The employee, employee’s supervisor, University Hospital Emergency Department (ED) and/or your private medical provider are responsible for completing their section(s) of this report. If you have not received medical attention at this time, this must be noted on the report. NOTE: If medical attention is sought at a later date, documentation must be provided from your private medical provider to Human Resource Services, Research Foundation Benefits z=0751. Human Resource Services, Research Foundation Benefits will notify Environmental Health & Safety (EH&S), z=6200 for OSHA recordkeeping purposes.
4. All occupational injuries or illnesses that occur to employees while on duty must be promptly reported by the employee to fulfill legal reporting requirements under the NYS Workers’ Compensation Laws and the Occupational Safety and Health Administration (OSHA).
5. Complete the Research Foundation Work-Related Employee Injury/Illness Incident Report within 24 hours after a work-related injury or illness. Return the completed report to your supervisor or designee for proper distribution.
6. Supervisors are required to perform an investigation of the injury or illness to determine the root cause(s) and their corrective action(s) to be taken to prevent the incident from being repeated. This information must be provided in the 'Supervisors Statement' section of the report.
7. The Research Foundation Work-Related Employee Injury/Illness Incident Report must be completed in its entirety and signed legibly.
8. If the employee was exposed to a hazardous material or a bloodborne pathogen (BBP) the employee must be evaluated by the Department of Occupational and Environmental Medicine or the University Hospital Emergency Department (ED); however, the employee is not required to accept treatment. If the injury involves a BBP they must be evaluated within 2 hours of the injury.
9. Notify your direct supervisor or their designee and Human Resources Services, Research Foundation Benefits if your private medical provider extends the off-duty time beyond the time authorized by the Department of Occupational and Environmental Medicine or the University Hospital Emergency Department (ED).
10. If subsequent medical attention is received, documentation must be provided from your private medical provider to Human Resources Services, Research Foundation Benefits. The note from your private medical provider should contain a diagnosis code, prognosis, and estimated date of return.

Important: Promptly completing all of the above steps for reporting your work related injury/illness will ensure payment of all your compensable medical bills and lost work time. In order for Chubb Insurance to evaluate your case for payment of your Workers’ Compensation wage replacement benefits and medical bills they need to have a copy of your injury/illness report from your employer and a medical report from a physician indicating your disability is due to your job-related injury.

Please complete the Stony Brook Medicine Injury/Illness Report. 

This report contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.

Any employee who files a false report will be subject to the appropriate administrative action including disciplinary action pursuant to the applicable collective bargaining unit.

Employee instructions: 

1. Report your injury or illness to your direct supervisor or their designee.
2. Get medical attention if needed. Report to Employee Health Services or the Emergency Department (ED) during off hours or in a life-threatening emergency, and inform them that your injury is work-related. Employee Health Services or the ED will complete their portion of this report. If you have not received medical attention at this time, this must be noted on the form. If medical attention is sought at a later date, documentation must be provided from your private medical provider to Timekeeping (z=9121).
3. All occupational injuries or illnesses that occur to employees while on duty must be promptly reported by the employee to fulfill legal reporting requirements under the NYS Workers’ Compensation Laws and the Public Employee Safety and Health Bureau (PESH).Complete this report within 24 hours after a work-related injury or illness. Return this completed report to your supervisor or designee for proper distribution.
4. In addition to completing this report, the employee must call the NYS Accident Reporting System (ARS) at (888) 800-0029 to report the incident and receive an incident number.
5. If the employee was exposed to a hazardous material or a bloodborne pathogen (BBP) the employee must be evaluated by Employee Health or the ED; however, the employee is not required to accept treatment. If the injury involves a BBP they must be evaluated within two hours of the injury.
6. Notify your direct supervisor or their designee and Timekeeping if your private medical provider extends the off-duty time beyond the time authorized by Employee Health Service or the ED.
7. If subsequent medical attention is received, documentation must be provided from your private medical provider to Timekeeping. The note from the provider should contain a diagnosis code, prognosis, and estimated date of return.
8. Report any medical equipment incidents to Biomedical Engineering (444-1420).

Important: Promptly completing all of the above steps for reporting your work related injury/illness will ensure payment of all your compensable medical bills and lost work time. In order for the New York State Insurance Fund to evaluate your case for payment of your Workers’ Compensation wage replacement benefits and medical bills they need to have a copy of your injury/illness report from your employer, ARS notification, and a medical report from a physician indicating your disability is due to your job-related injury.

Supervisor instructions:
Please make a photocopy of this report for your records.

Distribution list for hospital employees:

• Original (White): Timekeeping, z=9121
• Green: Environmental Health & Safety, z=8017
• Yellow: Workers’ Compensation, z=7010
• Pink: Employee Health, z=7409
• Orange: Employee

Distribution List for LISVH employees only:

• Original (White): LISVH Human Resources, z=9500
• Green: Supervisor
• Yellow: Employee

It is also important for students, faculty, and staff to report to their supervisor or professor all near misses that had the potential to cause serious injury or harm. Near misses provide you with the opportunity to correct potential hazards before an injury occurs. Near misses can be reported to Environmental Health & Safety at (631) 632-6410.