objective of this procedure is to meet our legal obligations by assuring
correct, adequate, and prompt reporting of all accidents, and to make
sure that all necessary agencies are notified of each injury.
injured employee or student must report any accident where medical attention
and/or first aid is required, or whenever any apparent bodily injury
was received by the injured. Student
accident reports will be completed by the University Health Service
if the student reports to the Health Services.
Obligations of Injured / Ill Employee
1. Get medical help if needed. Report your injury/illness to your supervisor.
All employees must complete a form CS-13, Report of Accident
or Injury, within 3 days after the date of the incident.
Retain a copy for your files.
Forward the original to your supervisor who will complete their
portion. Supervisors are to forward the original to Human Resources, with a copy going to the Environmental Health
and Safety Office (EH&S) . If assistance is required
in completing the form, call the EH&S office at 7-2211.
All classified employees (those represented by CSEA, PEF, Council
82, plus M/C Classified) may also call the Accident Reporting System
(ARS) at 1-888-800-0029 (toll free) 24 hours a day (any day).
Such calls allow for immediate access to Workers Compensation
Benefits. The ARS operator will provide an incident number
which CSEA and/or Empire Plan members can use to access a work related
prescription drug benefit under the name of ONECARD Rx.
B. Obligations of Supervisor of Injured Person
Complete a form CS-13, Report of Accident
or Injury, within 3 days after the date of the incident. Retain a copy for your files.
Forward the original to Human Resources, and a copy to the Environmental Health &
Safety Office, Health Services Building. If
assistance is required in completing the form, call the EH&S office
C. Number of Reports Required
Use one report form for each person injured even though
the injured person may have multiple injuries.
A separate report must be filed for each injured person
whenever an injury involves two or more people.
D. Definition of Terms
Employee as used in this procedure, means a person who is on a State payroll
at the time of the injury.
This, therefore, does not include employees of the
Research Foundation, auxiliary campus enterprises (Bookstore, Vending,
Dining Services) and similar organizations.
Accidents causing injuries to such non-State employees will be
reported as public injuries. Students
working for the college and temporarily on State payroll at the time
of the accident will be included as employees.
Student, as used in this procedure, includes campus school pupils as well as
all other students. All accidents
causing injuries involving students not working for the
college at the time of the accident will be reported as public
Supervisor means the immediate supervisor of the involved employee or student.
Reportable Accident is an accident where medical attention and/or first
aid is required or any apparent bodily injury was received by the injured.
Major Injury - When an accident results in the loss of one or more full work shifts
or days of class time, it is considered a lost-time or disabling injury
and should be reported as a major injury.
Injuries about which you have doubt should be reported
as major injuries.
Minor Injury - Includes all reportable accidents which do not meet the definition
of major injury as defined above.
E. Instructions for Completing Form CS-13
(A Sample Form filled out correctly follows these directions):
Item 1 - Campus - This part has been completed for you. The Binghamton University campus code is 2802.
Item 2 - Date and time of accident - Indicate the numerical designation for the date
of occurrence. Use zeros as
appropriate, i.e.: 08/01/81. Indicate
the time of occurrence using military 24 hour time, i.e.: 9:30 a.m.
should be 0930, 4:15 p.m. should be 1615.
(Simply add 12 hours to the p.m. time to get military time, i.e.:
12 + 4:15 p.m. equals 1615; 12 + 1:05 p.m. equals 1305, etc.).
Item 3 - Date of report - Indicate the numerical designation for the date
of the report.
Item 4 - File ID - The file number will be assigned by the EH&S
Item 5 - Did accident involve personal injury - Signify by placing an "A" for yes, a
"B" for no. Note:
the letter designation is to be placed in the area provided.
Item 6 - Victim status - Signify by placing the appropriate letter in the
Item 7 - Name of office/department where employee
is regularly assigned
- This section is applicable only to employees.
Fill in the name of the office/department where assigned even
though the accident may have occurred at some other location.
Worker's Compensation Board requires items 8, 9, 11, and 12 to be completed.
Item 8 - Sex - Signify the sex of the injured by indicating an "A" for
female, "B" for male.
Item 9 - Date of birth - Indicate the numerical designation for the victim's
date of birth.
Item 10 - Name of victim - Print the victim's name in the space provided,
starting with the last name. Print
the victim's local address, telephone number, home address (if different),
and telephone number.
Item 11- Martial status - Place the appropriate letter in the space provided.
Item 12- Social Security Number - Complete as appropriate; if the victim does not
have a social security number, indicate "none." If unknown, leave blank.
Item 13- Job title and grade - Complete with regularly assigned job title and
grade even though the victim may have been temporarily assigned to another
Item 14- Employment date - Indicate the numerical designation for the date
of when the employee began working for the University. If unknown, leave blank.
Item 15- Was victim in authorized area - Signify with the appropriate letter in the space
Item 16- Reporter of accident - This question pertains to the reporter, not the
victim. Signify with the appropriate letter in the space provided.
Item 17- Name of reporter of accident
- Print the name and address of the reporter of the accident.
Start with the last name first in the spaces provided.
Item 18- General area of occurrence - Indicate the general area of occurrence by placing
the appropriate letter in the space provided.
Item 19- Specific area of occurrence - If the accident occurred in a building, write in
the building name and indicate the room number in the space provided. If outside a building, briefly describe the
area, i.e.: North of Library Tower.
Item 20- If physical injury, part of body injured - Specify the part of the body injured by placing
the appropriate letter in the space provided.
Indicate right or
left side or finter/toe #.
Item 21- If physical injury, type of injury - Indicate the type of injury by placing the appropriate
letter in the space provided.
Item 22- If physical injury, extent - Indicate the extent of the physical injury. A major injury is any lost time injury. (See definition of terms). A minor injury is one where the employee is
able to resume work without lost time.
Item 23- If physical injury, nature - The nature of the physical injury is usually determined
by medical personnel. If there
is any doubt leave this question blank.
Item 24- Accident - Use the appropriate letter to indicate the relationship
of the accident with the University.
Item 25- Were safeguards provided - If the activity being performed at the time of
the accident required safeguards, i.e.: safety glasses, machine guards,
hard hats, etc., were they provided?
Use "A" for yes, "B" for no.
Item 26- Were safeguards in use - Were the safeguards mentioned in item 25 actually
being used at the time of the accident?
Item 27- Are there witnesses - If the answer is yes, give the names and addresses
(if known) in the narrative.
Item 28- Medical assistance rendered - Describe the type of medical assistance the victim
received. If none, write none.
Item 29 - Name and address of physician - If the injured was seen by a physician, give the
name and address of the physician in the space provided.
Item 30 - Name and address of hospital - If the injured was taken to a hospital, give the
name and address of the hospital in the space provided.
Item 31 - Has the employee returned to work - If the injured missed work and has returned by
the time the report is written, indicate yes by using the letter "A"
and fill in the numerical designation for the date the employee returned. Use the letter "B" to indicate no.
If the employee did not miss work (minor injury) leave blank.
Item 32 - Employee has restricted duties - If as a result of the accident the injured cannot
return to his normal duties or can only perform restricted duties, indicate
with the appropriate letter in the space provided.
Item 33 - Supervisor notified - Indicate with the letter "A" for yes,
and complete the numerical designation for the date. Use military hour time (see item 2) for the time of notification.
Use letter "B" to indicate no.
Item 34 - Name of supervisor - Print the name of the injured employees immediate
supervisor whether or not he/she was notified at the time of the accident.
Narrative - Give a brief description of the accident. Include the who, what, when, where, and how, etc. of the accident.
List the names and addresses, if known, of all witnesses. You
may attach a separate sheet of paper as a continuation sheet.
indicate right or left side or finger/toe #.
Report completed by - Please print your name, title, and the date of
Safety Supervisor's signature - This section will be signed by the EH&S Associate
Director upon review of the report.