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 is Required
Local jurisdiction in which the incident occurred:	*Local jurisdiction is Required
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 *Age is Required
Sex:	Select... Male Female *Sex is Required
Job Title / Classification:	*Job Title is Required
Member Card Number:	*Card Number is Required
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 *Years as Member is Required
Email Address (optional)

Employer Information

Company Name	*Company Name is Required
City where injury occurred:	*City Name is Required
State / Province:	*State/Province is Required

Event Information

Type of Injury (example: fall, cut, burn, struck by, etc.):	*Type of Injury is Required
Date of Injury (MM/DD/YYYY):	*Date of Injury is Required
Job Injury Location:	Utility Construction Maintenance Residential Material Handling Other *Job Injury Location is Required
Crew Size (Number):	*Crew size is Required
Disability:	Temporary Permanent Total Permanent Partial Partial Fatality *Disability is Required
Description of conditions under which the injury occurred (Please include immediate supervisor, job assignment, event detail, unsafe procedures, and prevention measures put in place.)
*Description of Conditions is Required
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 *Citation issued is Required
(If Yes above) Agency:
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