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LS54 Form Template

Streamline Compliance with the LS54 Form Template

Struggling to stay compliant with New York's Section 195.1 Labor Law? This LS54 form template is tailored for government agencies and companies looking to simplify their reporting process. By using this template, you'll ensure accuracy, save time on paperwork, and keep your business aligned with state regulations. With user-friendly fields, pre-set guidelines, and WCAG-aligned labels for accessibility, it's designed to make your form submissions straightforward and efficient. Check out the live template to get started today.

Use this Template (FREE) Live Preview
Full name
Email address
Phone number
Postal address
Organisation, court, or agency related to this LS54 submission
Case or reference number (if applicable)
Brief description of the matter
Purpose of this LS54 submission
Application
Appeal
Complaint
Request for information
Other/Not sure
Names and roles of other parties (if any)
Are you the primary applicant for this matter?
Yes
No
Summary of relevant facts or background
Do you have supporting documents to submit with this LS54?
Yes
No
I confirm the information provided is accurate and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I understand this information may be shared with relevant parties as required for processing.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Preferred contact method for updates about this LS54
Email
Phone
Either email or phone
Prefer not to be contacted
Do you consent to being contacted about this submission?
Yes
No
Full name (as signature)
Date signed
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Paper art illustration representing LS54 Form Template for FormCreatorAI article

When to use this form

Use this template to record a significant incident, loss, or security event so your team can investigate and act. It helps facilities, security, IT, and HR capture a time-stamped account from the person reporting. Common cases include a missing laptop, a minor injury in the warehouse, or a disruption in a classroom. If the event involves theft, attach a Stolen property report form to capture item details and serial numbers. For injuries, pair this with the Employee injury report form to route it to HR. When the matter is resolved, hand off the summary to the Case closure form to document outcomes and follow-ups.

Must Ask LS54 Questions

  1. What happened, in your own words?

    A clear, plain narrative sets scope and reduces back-and-forth. Specifics about actions, items, or damage help triage and assign the right team.

  2. When and where did the incident occur?

    Time and location anchor the event and enable log checks or camera reviews. They also help connect related reports from the same period or area.

  3. Who was involved and how can we contact them?

    Names, roles, and contact details speed follow-up and witness statements. They also clarify whether HR, security, or IT should lead.

  4. What evidence or documents can you provide (photos, receipts, IDs, logs)?

    Attaching files strengthens claims and speeds validation. If the issue was technical, cross-reference a Software incident report form to route it to IT.

  5. Has this been reported elsewhere, and what actions have been taken so far?

    Noting prior reports and actions prevents duplicate work and shows urgency. It also reveals who is accountable next and what approvals are pending.

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