JT2 Integrated Resources |
State of California EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS |
OSHA CASE NO.
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FATALITY
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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
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1a. Policy Number
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Please do not use this column |
2. MAILING ADDRESS:(Number, Street, City, Zip)
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2a. Phone Number
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CASE NUMBER
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3. LOCATION If different from Mailing Address (Number, Street, City and Zip)
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OWNERSHIP
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4. NATURE OF BUSINESS; e.g. Painting contractor, wholesale grocer, sawmill, hotel, etc.
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5. State unemployment insurance account number.
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INDUSTRY
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6. TYPE OF EMPLOYER:
Private
State
County
City
School District
Other Gov’t Specify
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OCCUPATION
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10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
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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)
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13. DATE RETURNED TO WORK (mm/dd/yy)
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14. IF STILL OFF WORK, CHECK THIS BOX:
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AGE
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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)
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18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM (mm/dd/yy)
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DAILY HOURS
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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
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DAYS PER WEEK
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20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
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20a. COUNTY
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21. ON EMPLOYER'S PREMISES?
Yes
No |
WEEKLY HOURS
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22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.
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23. Other Workers injured or ill in this event?
Yes
No |
WEEKLY WAGE
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24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
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COUNTY
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25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
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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.
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NATURE OF INJURY
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27. Name and address of physician (number, street, city, zip)
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27a. Phone Number
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PART OF BODY
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28. Hospitalized as an inpatient overnight?
Yes
No
If yes, then name and address of hospital (number,street,city,zip)
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28a. Phone Number
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29. Employee treated in emergency room?
Yes
No |
SOURCE
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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
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31. SOCIAL SECURITY NUMBER
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32. DATE OF BIRTH (mm/dd/yy)
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EVENT
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33. HOME ADDRESS (Number, Street, City,Zip)
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33a. PHONE NUMBER
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34. SEX
Male
Female |
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
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36. DATE OF HIRE (mm/dd/yy)
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SECONDARY SOURCE
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37. EMPLOYEE USUALLY WORKS
hours per day
days per week
total weekly hours
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37a. EMPLOYMENT STATUS
regular, full-time
part-time
temporary/seasonal
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37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED
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38. GROSS WAGES/SALARY
$
per
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39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)?
Yes
No |
EXTENT OF INJURY
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Completed By
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Signature & Title (Typing your name below acts as you signature.)
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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. |
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FORM 5020 (Rev 7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY