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First Report of Injury
in New York

Name(Required)
Mailing Address:(Required)
MM slash DD slash YYYY
Gender:(Required)
Will you need a translator if you have to attend a Board hearing?(Required)

MM slash DD slash YYYY
Your Work Address:(Required)
Supervisor's Full Name:(Required)
Did you lose time from work at the other employment(s) as a result of your injury/illness?(Required)
Did you have more than one employer at the time of your injury/illness?(Required)

Was your job?(Required)
Did you receive lodging or tips in addition to your pay?(Required)

MM slash DD slash YYYY
Time of injury:
:
Was this your usual work location?(Required)
Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?(Required)
Was the injury the result of the use or operation of a licensed motor vehicle?(Required)
Have you given your employer (or supervisor) notice of injury/illness?(Required)
Did anyone see your injury happen?(Required)

Did you stop work because of your injury/illness?(Required)

Did you receive treatment for your injury or illness?(Required)
Have you had another injury to the same body part, or a similar illness?(Required)

NOTICE:(Required)
Prepared By:(Required)
Completed by:(Required)
This field is for validation purposes and should be left unchanged.