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Part A records witness information and a complete narrative of what occurred, how it occurred, and why. Supervisor and department head sections capture reporting time, medical treatment location, investigative results, corrective actions, and required signatures. Part B and Part C gather attending physician details and environmental health & safety classification for OSHA recordability.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/employee-incident-report-part-a-employee-and-employer-statement-form/253208/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/employee-incident-report-part-a-employee-and-employer-statement-form/253208.png","ImageObject",442,249,{"name":88,"@type":89},"Margaret","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must the employee and/or supervisor provide in Part A of the incident report?","Question",{"text":109,"@type":110},"Part A collects incident date and time, the employee’s name and identifiers, job title and department, location where the incident occurred, nature of injury or illness, and any exposure details. It also includes a narrative description and witness names and phone numbers.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the report address sharps injuries and potential infectious material exposure?",{"text":114,"@type":110},"Part A asks whether the incident was a sharps injury, whether the object had a safety device, the type and brand of the device, and whether the needle or object was contaminated with blood or other potentially infectious material (OPIM).",{"name":116,"@type":107,"acceptedAnswer":117},"What additional details are collected in Part B and Part C of the incident report?",{"text":118,"@type":110},"Part B captures whether the employee can return to work, hospitalization and medication information, and the treatment received, along with physician identity and contact details. Part C is used for environmental health & safety classification, including whether the incident is OSHA recordable.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},253208,1789264671,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":73},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","􀂆  \n􀂆  \nBeth Israel Medical Center  \nSt. Luke’s Hospital  \n􀂆  \n􀂆  \nBeth Israel Brooklyn  \nRoosevelt Hospital  \nEMPLOYEE INCIDENT REPORT – PART A EMPLOYEE AND EMPLOYER STATEMENT  \n\n| Section I TOBE COMPLETED BY EMPLOYEE AND/OR SUPERVISOR |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Date of Incident |  |  | Time of Incident\u003Cbr>  􀂆 AM 􀂆 PM |  |  |  | Time work shift began\u003Cbr>  􀂆 AM 􀂆 PM |  |  |\n| Employee’s Name |  |  | Home Address (include City, State and Zip Code) |  |  |  |  |  |  |\n| Home Telephone |  |  | (Payroll) Employee Number (6 digits) |  |  |  | Date ofBirth |  | Gender\u003Cbr>􀂆 M 􀂆 F |\n| Social Security Number |  | Employee’s Job Title |  |  | Employee’s Department |  |  | Date of Hire |  |\n| Job Experience (Years and Months in Profession) |  |  |  | Location where incident occurred (building, department, floor, room) |  |  |  |  |  |\n| Nature of Injury or Illness (e.g., needle stick to finger, strain to lower back, chemical splash to eye). Specify any object/substance that caused the injury/illness: |  |  |  |  |  |  |  |  |  |\n| If incident involves exposure to patient body fluid(s), provide Source Patient Medical Record \\# : |  |  |  |  |  |  |  |  |  |\n| Was this a “Sharps”injury?\u003Cbr>􀂆 Yes 􀂆 No | If yes, did object have a safety device?\u003Cbr>􀂆 Yes 􀂆 No |  |  | Specify type and brand of device: |  | If a “Sharps” injury, was the needle or object contaminated with blood or other potentially infectious material (OPIM)?\u003Cbr>􀂆 Yes 􀂆 No |  |  |  |\n| What was employee doing when he/she was injured or became ill? (e.g., suturing wound, lifting patient, carrying equipment, etc.) |  |  |  |  |  |  |  |  |  |\n| Provide a complete description of the incident (what occurred, how it occurred, why it occurred) |  |  |  |  |  |  |  |  |  |\n| Name of Witness 1 and Telephone Number |  |  |  |  | Name of Witness 2 and Telephone Number |  |  |  |  |\n| Name of Witness 3 and Telephone Number |  |  |  |  | Name of Witness 4 and Telephone Number |  |  |  |  |\n\n\n| EMPLOYEE INCIDENT REPORT – PART A (continued) |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Section II TOBE COMPLETED BY SUPERVISOR AND DEPARTMENT HEAD |  |  |  |  |  |  |  |  |\n| EMPLOYEE’S NAME: |  |  |  | DATE OF INCIDENT: |  |  |  |  |\n| Date incident was reported to you |  |  | Time Reported:\u003Cbr>  􀂆 AM 􀂆 PM |  |  | Did employee return to work (not counting day of incident)? 􀂆 Yes 􀂆 No |  |  |\n| What is the last date the employee worked? | What is the first date employee was absent from work (based on usual work schedule)? |  |  |  |  |  | What date did or will employee return to work? |  |\n| Employee Treated In:\u003Cbr>􀂆 E.R. 􀂆 Employee Health Services 􀂆 Private MD 􀂆 Other   􀂆 Refused Treatment |  |  |  |  |  |  |  |  |\n| Body Part Injured (be specific – e.g., index finger on left hand, right hip, calf on right leg) |  |  |  |  |  |  |  |  |\n| Provide the results of your investigation including photographs and diagrams: |  |  |  |  |  |  |  |  |\n| What Corrective Actions have been taken or need to be taken to prevent additional occurrences? |  |  |  |  |  |  |  |  |\n| Section III REQUIRED SIGNATURES |  |  |  |  |  |  |  |  |\n| Name of Employee |  | Signature |  |  | Date |  |  | Work Telephone |\n| Employee Email Address: |  |  |  |  |  |  |  |  |\n| Name of Supervisor |  | Signature |  |  | Date |  |  | Work Telephone |\n| Supervisor Email Address: |  |  |  |  |  |  |  |  |\n| Name of Department Head |  | Signature |  |  | Date |  |  | Work Telephone |\n| Department Head Email Address: |  |  |  |  |  |  |  |  |\n\nEmployee’s supervisor or other designated departmental staff:  \n1. should print PART A of this report and obtain required signatures  \n2. Obtain completed PART B from the employee  \n3. scan and send both Part A and Part B (the physician’s statement) via email* to the following departments:  \nDepartment  \nHuman Resources Benefits Division  \nEmployee Health Services (EHS)  \nEnvironmental Safety D","cbCaipc1bMoyi087","https://ap.wps.com/l/cbCaipc1bMoyi087","pdf",241200,"English","# EMPLOYEE INCIDENT REPORT - PART A EMPLOYEE AND EMPLOYER STATEMENT\n## Section I - To be completed by employee and/or supervisor\n## Section II - To be completed by supervisor and department head\n## Section III - Required signatures\n# EMPLOYEE INCIDENT REPORT - PART B ATTENDING PHYSICIAN'S STATEMENT\n## To be completed by employee\n## To be completed by treating physician\n# EMPLOYEE INCIDENT REPORT - PART C (FOR ENVIRONMENTAL HEALTH & SAFETY USE ONLY)","[{\"question\":\"What information must the employee and/or supervisor provide in Part A of the incident report?\",\"answer\":\"Part A collects incident date and time, the employee’s name and identifiers, job title and department, location where the incident occurred, nature of injury or illness, and any exposure details. It also includes a narrative description and witness names and phone numbers.\"},{\"question\":\"How does the report address sharps injuries and potential infectious material exposure?\",\"answer\":\"Part A asks whether the incident was a sharps injury, whether the object had a safety device, the type and brand of the device, and whether the needle or object was contaminated with blood or other potentially infectious material (OPIM).\"},{\"question\":\"What additional details are collected in Part B and Part C of the incident report?\",\"answer\":\"Part B captures whether the employee can return to work, hospitalization and medication information, and the treatment received, along with physician identity and contact details. Part C is used for environmental health \\u0026 safety classification, including whether the incident is OSHA recordable.\"}]","Employee Incident Report - Part A Employee and Employer Statement - Form | PDF"]