Injury/Fatality Incident Information
 


Property owners, contractors, subcontractors, and persons otherwise in control of a construction site for which a permit is required are required to provide to DOB, within 3 business days of the incident, specific information about incidents that resulted in fatalities or injuries to members of the public or construction workers. (See § 28-103.21 of the New York City Administrative Code.)

Use this form to provide required information about the incident. You can find some of the required information including violations and active permits in the Building Information System or the DOB NOW Public Portal. Failure to submit this form or provide all of the required information within 3 business days of the incident may result in a violation and a penalty of up to $5,000.
Incident Location  
*Borough *House Number *Street Name *Zip Code *Owner of Site
Person Reporting  
*Person Reporting
*Person in Control of Site
*Other Description
*Person Reporting Type
*Last Name *First Name *License Number *E-mail
*Contact Name (Last, First) *Business Name *License Number *E-mail
*House Number *Street Name Apt/Suite
*City *State *Zip Code *Phone
999-999-9999
Incident Information  
*Date and time of the incident/fatality
Incident Number, if available(This number would have been provided by DOB if the incident was previously reported by phone)
*Was the construction site where the incident occurred    Union      Non-Union      Open Shop     
*Did incident involve a construction worker?   Yes      No     
   *General Contractor or Subcontractor who employed such worker at the time of the incident. 
   
   *Last Name
*First Name
License Number
   
   *Business Name
License Number
   
*Detailed description of the incident (Detailed description of the incident, including the nature of the work being performed at the time of the incident.)*
(Maximum limit: 600 Characters)
*Number of persons injured in the incident  
        
*Number of fatalities in the incident             
        
Building, Violation, Permit Information  
*Number of Violations issued by DOB as a result of the incident  
*Total square footage of the site where the incident occurred   
        sq. ft.
*Was the building where the incident occurred a new or existing building?   New     Existing     
      *Proposed Number of Floors   *Proposed Height   
       floor(s)       ft.      
      *Existing Number of Floors   *Existing Height   
       floor(s)       ft.      
*Number of active permits issued by DOB for the site:  


 
 
 












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