Follow these instructions:

1. The INJURED PARTY completes Section 1:
   • after completing it, sign and date Section 1,
   • give Accident Report to supervisor.
2. The SUPERVISOR to whom the injury was reported completes Section 2:
   • after completing it, sign and date Section 2,
   • make a photocopy of report for the injured party's personal records,
   • give original Accident Report to an authorized department personnel (personnel officer, administrator, payroll coordinator, etc.).
3. The DEPARTMENT PERSONNEL completes Section 3:
   • after completing it, sign and date Section 3,
   • make sure Sections 1 & 2 are complete and signed,
   • make two photocopies: keep one copy for department files, send second copy to:

     Lenny Solomon
     Chair of Safety Committee
     The Link (Mallinckrodt), Rm. 264

   • immediately send the original completed Accident Report to:

     Disability Claims Unit
     Holyoke Center 6th Floor
     1350 Mass. Ave.
     Cambridge, MA 0213

Questions? Please telephone the Disability Claims Unit at 495-9054.