Disability benefits program - Northeastern University 2025

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The document is a Workers' Compensation Accident/Illness/Near Miss Report Form for Northeastern University, designed for employees and supervisors to report work-related injuries, illnesses, or near misses. It outlines the procedures for completing the form, including immediate reporting requirements, necessary signatures, and medical authorization. The form must be submitted within 24 hours of an incident to the Office of Risk Services or via email. It includes sections for employee and supervisor statements, as well as a medical records release authorization.

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Click ‘Get Form’ to open the Workers’ Compensation Accident/Illness/Near Miss Report Form in the editor.
In Part A, enter your personal information including your name, employee ID, date of birth, and home address. Ensure all fields are filled out accurately.
Provide details about the accident or near miss in the description section. If necessary, attach a separate sheet for additional information.
Sign and date the form at the bottom of Part A to confirm your statement is complete and accurate.
Part B must be completed by your supervisor. Ensure they discuss the incident with you before filling it out.
If medical treatment was received, ensure that a work clearance note is attached before submitting the form.
Submit the completed form via email to insurance@northeastern.edu or deliver it to the Office of Risk Services within 24 hours of the incident.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (91 Votes)
2018	4.4 Satisfied (56 Votes)
2015	4 Satisfied (28 Votes)

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