New York incident report template

New York rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

• An employer, or a third party it designates, records any injury or illness an employee incurs in the course of employment on the form the Chair prescribes for injury reports, gives the employee a copy on request, and keeps it at least eighteen years, subject to the Chair's review at any timeN.Y. Workers' Compensation Law 110 (1)
• Within ten days after the accident, the employer files with the Chair of the Workers' Compensation Board, and with its carrier if insured, a report of any accident that causes lost time beyond the working day or shift of the accident, or that needs medical treatment beyond ordinary first aid or more than two first aid treatments; occupational diseases are reported on the same formN.Y. Workers' Compensation Law 110 (2)
• The report states the employer's name and business, the location of the establishment or place of work, the injured employee's name, address and occupation, and the time, nature and cause of the injuryN.Y. Workers' Compensation Law 110 (2)
• A recorded injury that did not need reporting is filed with the Chair once its status changes to lost time or medical treatment that requires reporting; injuries that never need reporting are not used for experience modification if the employer pays for the treatmentN.Y. Workers' Compensation Law 110 (1), (3)
• An employer that refuses or neglects to make a report or keep records is guilty of a misdemeanor with a fine of up to 1,000 dollars, and the Board or Chair may impose a penalty of up to 2,500 dollars for failing to reportN.Y. Workers' Compensation Law 110 (4)
• The carrier (or self-insured employer) gives the injured employee a written statement of their rights within fourteen days of receiving the report or with the first check, whichever comes firstN.Y. Workers' Compensation Law 110 (2)
• The employee gives the employer written notice within thirty days after the accident, signed, with the employee's name and address and the time, place, nature and cause of the injury in ordinary language; a late notice can be excused if the employer's supervisors knew or the employer was not prejudicedN.Y. Workers' Compensation Law 18

What is in it

• What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
• Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
• Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
• Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
• CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
• Witness statementsName, Role, What they saw or said
• Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 15, 2026. Read the full New York incident report requirements.