Employee Accident or Injury Information

Name*

First Name

Last Name

Date of Birth

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Gender

Male Female Prefer Not to Answer

Home Phone*

xxx xxx xxxx

Person Number*

Your Email Address*

Preferred: UB email address

Work Status*

Full-time Part-time

Other:

Job Title*

Usual Work Days

Monday-Friday Weekends Only As Scheduled (Monday-Sunday)

Other:

Supervisor's Name*

Usual Work Hours

For example: 9am-5pm

Department

Line Number

Department Address

Building, Room

State Bargaining Unit

CSEA GSEU M/C Classified M/C Professional NYSCOPA PBANYS PEF UUP

Department Phone

xxx-xxx-xxxx

Part 1 — Employee Information