Workers Compensation COVID Exposure Notification Form

No one knows the long-term health effects of COVID-19 exposure, so it’s essential that you protect your right to medical care and wage replacement through New York’s workers’ compensation system. Future benefits for you and your family could hinge on steps you take in the coming weeks.

The state’s workers compensation system requires employer notification within 30 days of the incident or exposure, so NYSNA is encouraging all exposed members to notify their employer. (While the board may accept a different standard for COVID-19 illness down the road, at this time it is imperative that members notify their employer as soon as possible.)

We have set up this easy-to-use form to help you protect yourself and your family. By submitting this form, you will officially notify your employer of your exposure. A copy of your email will be sent to you for your records.

Your Contact Info

Your name

Your Email

Mobile Number

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

Exposure Information

Facility

For H+H facilities, scroll down to "NYC Health + Hospitals" and find your facility there. If your facility is not listed, contact data@nysna.org for help.

Date of first exposure

Best approximate estimate.

Time of first exposure

Best approximate estimate.

Date exposure ended

Best approximate estimate. Leave blank of exposure continues

Date of first symptoms

If applicable

Date you were notified you tested positive for COVID-19

If applicable

Unit(s) where you were exposed to COVID

List all units where you believe you were exposed to the virus.

Consent to use NYSNA's COVID exposure form

I knowingly agree that by using NYSNA's technology to report my exposure to COVID-19, I consent to NYSNA receiving my personal medical information if management sends it to NYSNA accidentally.