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:	Select... 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Sex:	Select... Male Female
Job Title / Classification:
Member Card Number:
Years as member	Select... Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
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:	Utility Construction Maintenance Residential Material Handling Other
Crew Size (Number):
Disability:	Temporary Permanent Total Permanent Partial Partial Fatality
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.	Yes No
(If Yes above) Agency:
Verification Image	Show another code Type the code shown: The submitted code is incorrect
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