injury report - SUNY Upstate Medical University

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Part 3Please check all that apply with respect to your injury/illness. You should have at least one box checked in each column.Body Part(s) Nature of Injury/Illness Event(s)/Cause(s) Source(s)/Exposure(s)l Abdomen l Abrasion(s)/Scrape(s)/Scratch(es) l Alleged Assault l Animall Ankle (Left) l Allergic Reaction(s) l Alleged Harassment l Bacteria, Virus, Fungusl Ankle (Right) l Bite(s)/Sting(s) l Bending/Stooping l Bed/Standl Arm (Left) l Breathing Difficulty l Climbing l Blood/Body Fluidsl Arm (Right) l Burn(s) l Collapse l Body Movement/Motionl Back, Including Spine l Chest Pain l Collided with l Broken Glass, Sharp Objectl Body Systems l Head Injury l Computer Use l Buildings and Premisesl Breast (Left) l Contusion(s)/Bruise(s) l Construction l Carts/Dolliesl Breast (Right) l Crush Injury l Contact with l Chemical(s)l Buttock(s) l Repetitive Strain/Sprain l Fall l Cleaning Agent(s)l Chest l Death l Groundswork l Communicable Diseasel Ear (Left) l Dislocation(s) l Housekeeping l Computerl Ear (Right) l Dizziness l Ingestion l Coworkerl Elbow (left) l Electric Shock l Inhalation l Dust/Airborne Particlesl Elbow (Right) l Exposure(s) l Kneeling l Electricityl Eye (Left) l Foreign Body l Lifting l Elevatorl Eye (Right) l Broken Bone l Material Handling l Equipmentl Face l Headache l Needle Stick l Explosion and/or Firel Finger(s) (Left Hand) l Hearing Disorders/Loss l Overexersion l Falling Object(s)l Finger(s) (Right Hand) l Hernia l Patient Contact l Floorl Foot (Left) l Infectious/Parasitic Disease l Patient Handling/Transfer l Frictionl Foot (Right) l Internal Organ Injury l Pinched l Fume(s)/Noxious Odor(s)l Groin l Laceration(s)/Cut(s) l Pulling l Gas(es)l Hand (left) l Loss of Consciousness l Pushing l Groundl Hand (Right) l Mental Disorders/Stress/Anxiety l Reaching l Hand Tool(s)l Head l Muscle/Tendon/Ligament/Joint Inj. l Repetitive Work l Hot or Cold Temperaturel Hip (Left) l Nausea/Vomiting l Restraining Patient l Insect(s)l Hip (Right) l No Apparent Injury l Slip/Trip/Loss of Balance (w/o fall) l Instrument(s)l Internal Organ(s) l Numbness/Tingling l Spill l IV Tubingl Knee (Left) l Pain l Spray/Splash l Lightingl Knee (Right) l Paralysis/Weakness l Struck against l Loud Noisel Leg (Left) l Poisoning l Struck by l Motor Vehicle(s)l Leg (Right) l Puncture(s) l Needle(s)/Sharp object(s)l Lip(s) l Respiratory Distress/Shortness of Breath l Office Equipmentl Lung (Left) l Seizure l Organic Compoundsl Lung (Right) l Skin Disorder/Rash/Hives l Paints/Solventsl Mouth l Splinter(s) l Parking Garagel Neck l Sprain(s)/Strain(s) l Parking Lotl Nose l Swelling l Patientl Pelvis l Visual Disturbance(s) l Radiationl Ribs (Left Side)l Scaffoldl Ribs (Right Side)l Sidewalk/Curb/Pavementl Sacrum/Coccyxl Snow/Icel Shoulder (Left)l Stairwells/Shaftwaysl Shoulder (Right)l Steaml Skinl Stomachl Studentl Vibrationl Teethl Visitorl Thigh (Left)l Volunteerl Thigh (Right)l Water/Liquidl Thumb (Left)l Window/Doorl Thumb (Right)l Toe(s) (Left Foot)l Toe(s) (Right Foot)l Tonguel Wrist (Left)l Wrist (Right)l Other – List: l Other – List: l Other – List: l Other – List:Signature of Injured Person I request that my name not be entered on the ”Log of Work Related Injuries and Illness” DateTO BE COMPLETED BY THE HUMAN RESOURCES DEPARTMENT:ARS#: Case #: SIF#:Date Sent to: Supervisor: Employee Health: Risk Management:
STATE OF NEW YORKWORKERS’ COMPENSATION BOARD100 BROADWAY-MENANDSALBANY, NY 12241(877) 632-4996You were injured at work. What now?If you’ve suffered a workplace injury or illness, you may be eligible for workers’compensation benefits. You may have already received medical treatment. If youhaven’t, you should seek medical care as soon as possible.A Worker’s Responsibilities• You must tell your employer, in writing, when, where and how you were injured.Do this within 30 days of injury.• Medical reports are necessary for your case. Advise your doctors that you have a workrelatedinjury, and give the name of your employer. Do not pay for your careyourself or use other health insurance. Tell your doctor to file reports with the Boardand with your employer or its insurance carrier. If your case is disputed, the Boardneeds a medical report on your injury to begin resolving your claim.Starting a CaseOnce your employer knows of your injury, it must notify this Board by filing a C-2form. You should file an employee claim (C-3 form) reporting your injury as soon as possible.(You must notify the Board of your injury or illness within two years.) If you injured thesame body part before, or had a similar illness, you must also file a Form C-3.3.If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it.• Visit www.wcb.state.ny.us/content/main/onthejob/howto.jsp to complete the form.• Complete the enclosed paper forms, and mail them to the Board.• Call 1-866-396-8314. A Board employee will complete the form with you.Health Care BillsDo not pay your doctor or hospital. Those bills are paid by the insurer unless the Boarddisallows your case. If your case is disputed, the providers are paid when the Boarddecides your case. If the Board decides against you, or if you don’t pursue a case, you willhave to pay the doctor or hospital.Your employer’s insurance covers medically necessary drugs and equipment yourdoctor prescribes. You’re also entitled to carfare or necessary expenses incurred whentraveling for treatment. (Get receipts for those expenses.)THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
Page 1: NEW YORK STATE EMPLOYEE INJURY REPO
Page 5 and 6: Employee ClaimState of New York - W
Page 7 and 8: Limited Release of Health Informati
Page 9 and 10: Instructions for Completing Form C-
Page 11 and 12: ExpressComp ®Workers’ Compensati
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injury report - SUNY Upstate Medical University

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