How do I report an Injury or accident?

Chubb Insurance Accident Report Form (Supervisor’s Investigation Report)

This form must be sent to Chubb and copy must be e-mailed or mailed to NASDA.
Employee’s Report of Accident

Whenever a NASDA enumerative employee becomes involved in an accident regardless of its seriousness, the NAS-016 form must be completed. Examples of accidents would include the more obvious such as automobile and personal injury including ankle and leg injuries and dog bites. There will be occasions where the decision for filing this form becomes one of uncertainty. For instance, should this form be filed when, an enumerator has persistent back pain after moving a large stack of questionnaires, an enumerator becomes nauseous after being in a crop field for several hours, or an ankle aches after walking through a field to an Objective Yield sample?

When there is doubt about whether to report an incident, file the report so the facts can be recorded. The submission of this form does not automatically lead to any further action but does provide the opportunity to document the facts in a timely fashion.

The employee submitting the report must sign the document to verify the reported information is correct to the best of their knowledge. The report should then be forwarded to their supervisor for their attention. Supervisors should acknowledge the receipt of the report by dating the time they received the completed form. NASDA supervisors should use NAS-017 to report their findings to the NASS office after investigating the accident.

NASDA supervisors are responsible for filing and maintaining these reports for the duration of an enumerator’s employment plus five (5) years. The NASS office is responsible for filing and maintaining these reports for the duration of a supervisory enumerator’s employment plus five (5) years.

Supervisor’s Report of Accident

The Supervisor’s Report of Accident form provides a formal method for immediate supervisors to report the information they have collected after a NAS-016 has been filed. Supervisors need to be aware of the information required by the form so they will be prepared to complete the form accurately. It is important to complete this form in a timely fashion, before details become unclear to uncertain. Failure to report the incident in a timely fashion could disqualify the injured from being eligible for Worker’s Compensation. The supervisor should talk with any witnesses, if possible, to confirm or expand the details of the accident. The form must be fully completed with detailed descriptions of the accident and other details. The supervisor must sign and date the form for it to be acceptable.

This form will be kept on file in the Field office for five (5) years after the termination of the employee.