FORM 173 - Supplemental
Instruction to Worker, Steward, or Supervisor
  1. Fill out this form immediately in case of lost time accident or fatality
  2. This form must be completed by the injured worker, or if worker is unable to complete the form, the form must be completed by the steward of the immediate field supervisor.
  3. Return this form to the Local 20 Safety Committee within 36 hours of the incident

Note: This form is required by the IBEW Constitution (Article 15, Section 15).

Report of Occupational Injury, Illness or Fatality
(Note: All Entries are Required!)

Injured Person Information
Injured workers's Local Union Number:
 
Local jurisdiction in which the incident occurred:
 
Age:
 
Sex:
 
Job Title / Classification:
 
Member Card Number:
 
Years as member
 
Email Address (optional)
   
Employer Information
Company Name
 
City where injury occurred:
 
State / Province:
 
Event Information
Type of Injury (example: fall, cut, burn, struck by, etc.):
 
Date of Injury (MM/DD/YYYY):
 
Job Injury Location:




 
Crew Size (Number):
 
Disability:



 
Description of conditions under which the injury occurred (Please include immediate supervisor, job assignment, event detail, unsafe procedures, and prevention measures put in place.)
 
Agency Name(s): If accident is under investigation by a Federal or State Agency, which one(s)?
Citation(s): Has a citation, or citations, been issued by Federal, State or any government agency? If Yes, enter name of agency or agencies are investigating the incident in the space provided.
 

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