OSHA CASE NO.

FATALITY

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony.

California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

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1. FIRM NAME

1a. Policy Number

Please do not use this column

2. MAILING ADDRESS:(Number, Street, City, Zip)

2a. Phone Number

- -

CASE NUMBER

3. LOCATION If different from Mailing Address (Number, Street, City and Zip)

3a. Location Code

OWNERSHIP

4. NATURE OF BUSINESS; e.g. Painting contractor, wholesale grocer, sawmill, hotel, etc.

5. State unemployment insurance account number.

INDUSTRY

6. TYPE OF EMPLOYER:

OCCUPATION

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11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY?

Yes No

12. DATE LAST WORKED (mm/dd/yy)

13. DATE RETURNED TO WORK (mm/dd/yy)

/ /

14. IF STILL OFF WORK, CHECK THIS BOX:

AGE

15. PAID FULL DAYS WAGES FOR DATE OF INJURY OR LAST DAY WORKED?

Yes No

16. SALARY BEING CONTINUED?

Yes No

17. DATE OF EMPLOYER'S KNOWLEDGE / NOTICE OF INJURY/ILLNESS (mm/dd/yy)

/ /

18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM (mm/dd/yy)

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DAILY HOURS

19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning

DAYS PER WEEK

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)

20a. COUNTY

21. ON EMPLOYER'S PREMISES?

Yes No

WEEKLY HOURS

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.

23. Other Workers injured or ill in this event?

Yes No

WEEKLY WAGE

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold

COUNTY

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand.

NATURE OF INJURY

27. Name and address of physician (number, street, city, zip)

27a. Phone Number

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PART OF BODY

28. Hospitalized as an inpatient overnight? Yes No 
If yes, then name and address of hospital (number,street,city,zip)

28a. Phone Number

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29. Employee treated in emergency room?

Yes No

SOURCE

ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.

Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*

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30. EMPLOYEE NAME

31. SOCIAL SECURITY NUMBER

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32. DATE OF BIRTH (mm/dd/yy)

/ /

EVENT

33. HOME ADDRESS (Number, Street, City,Zip)

33a. PHONE NUMBER

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34. SEX

Male Female

35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

36. DATE OF HIRE (mm/dd/yy)

/ /

SECONDARY SOURCE

37. EMPLOYEE USUALLY WORKS

hours per day

days per week

total weekly hours

37a. EMPLOYMENT STATUS

regular, full-time

part-time

temporary/seasonal

37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED

38. GROSS WAGES/SALARY

$  per

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)?

Yes No

EXTENT OF INJURY

Completed By

Signature & Title (Typing your name below acts as you signature.)

Date (mm/dd/yy)

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Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and .federal workplace safety agencies.