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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







Employer Information



Event Information







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