Oklahoma Department of Labor PEOSH Division 3017 N Stiles, Suite 100 Oklahoma City, OK 73105 OFFICIAL STATE BUSINESS Public Sector Guidelines of Occupational Injuries and Illnesses Recordkeeping Year 20XX IMPORTANT NOTIFICATION BOOKLET The Oklahoma Department of Labor’s Public Employee Occupational Safety & Health Division (PEOSH) has issued revised forms. A copy of the new recordkeeping forms package is included for your convenience. |
An Overview: Recording Work-Related Injuries What do you need to do? and Illnesses The Oklahoma Occupational Health & Safety Standards Act (OOHSSA) requires all public sector employers with one or more employees to Within 7 calendar days after you receive information about a case, decide if the case is prepare and maintain records of all work-related injuries and illnesses. Use these definitions below when you classify cases on the OK300 Log. recordable under the recordkeeping Definitions are consistent with the OSHA Recordkeeping regulations, which have been adopted, in part, by the Oklahoma Department requirements. To do that, you must: of Labor. 1. Determine whether the incident is a new case or a recurrence of an existing one. The Log of Work-related Injuries and Illnesses Work-relatedness is presumed for injuries and ● tuberculosis infection as evidenced by a 2. Establish whether the case was work- (OK300) is used to classify work-related injuries illnesses resulting from events or exposures positive skin test or diagnosed by a physician or related. and illnesses and to note the extent and severity of occurring in the workplace unless an exception other licensed health care professional after 3. Identify the nature of the injury or illness, each case. When an incident occurs, use the Log to specifically applies. See 29 CFR 1904.5(b)(2) for exposure to a known case of active tuberculosis, the part of the body affected and the object or record specific details about what happened and the exceptions. The work environment includes the ● an employee's hearing test (audiogram) substance that caused harm to the employee. how it happened. establishment and other locations where one or reveals 1) that the employee has experienced a 4. Identify what medical treatment was more employees are working or are present as a Standard Threshold Shift (STS) in hearing in one provided and determine if the case is recordable The Summary of Work-Related Injuries & Illnesses condition of their employment. See 29 CFR or both ears (averaged at 2000, 3000 and 4000 according to the treatment provided or the (OK300A) - shows the totals for the year in each 1904.5(b)(1). Hz) and 2) the employee's total hearing loss level diagnosis of a significant injury or illness. category. At the end of the year, you must post the is 25 decibels (dB) or more above audiometric Summary in a visible location so that your Which work-related injuries and illnesses must zero (also averaged at 2,000, 3,000, and 4,000 If the case is recordable, complete a form OK301 and enter the injury on form OK300. employees are aware of the injuries and illnesses be recorded? Hz) in the same ear(s) as the STS. occurring in their workplace. Employers must keep Record those work-related injuries and illnesses a separate Log and Summary for each establishment that result in: What is medical treatment? When filling out the Forms, keep in mind... You must fill the forms out completely and in or site expected to be in operation for one year or ● death, Medical treatment means the management and detail. greater. Oklahoma Exception: Under 380:40-1-5, ● loss of consciousness, care of a patient to combat a disease or disorder. an establishment can include more than one ● days away from work, The following are not considered medical You must enter a case number, however, you are physical location, but only if the direct daily ● restricted work activity or job transfer, or treatments and are NOT recordable: allowed to codify your case numbers in any ● visits to a doctor or health care provider manner you find appropriate, so long as each supervision of all staff is the responsibility of one ● medical treatment beyond first aid. solely for observation or counseling, case number is unique. common individual. ● diagnostic procedures, including You must also record work-related injuries and administering prescription medications that are You must enter the employees' name, unless the Note, your employees have the right to review your illnesses that are significant (as defined below) or used solely for diagnostic procedures, and case meets the requirements of a "Privacy injury and illness records and they must be meet any additional criteria listed below. You must ● any procedure that can be labeled as first aid. Case", in which case, you must enter the words available for review by PEOSH Inspectors and record any significant work-related injury or illness (See below for more information about first aid.) "Privacy Case" in lieu of the employee's name. provided within 4 business hours of the initial that is diagnosed by a physician or other licensed request. Cases listed on the Log are not necessarily health care professional. You must record any What is first aid? In column F, you must enter three things: eligible for workers compensation or other work-related case involving cancer, chronic If the incident required only the following types 1. the exact nature of the injury, insurance benefits. Recording an injury or illness irreversible disease, a fractured or cracked bone, or of treatment, consider it first aid. Do NOT record 2. the part of the body affected, on the Log does not mean that the employer or the a punctured eardrum. See 29 CFR 1904.7. the case if it involves only: 3. what object or substance was that harmed worker was at fault or that a PEOSH or OSHA ● using non-prescription medications at the employee. standard was violated. PEOSH Regulations are What are the additional criteria? non- prescription strength, available at www.labor.ok.gov. You must record the following conditions when ● administering tetanus immunizations, Note: "knee pain" or "hurt back" are not they are work-related: ● cleaning, flushing or soaking wounds on acceptable descriptions of the injury. When is an injury or illness considered work- ● any needlestick or cut from a sharp object that the surface of the skin, related? is contaminated with another person's blood or ● using wound coverings, such as Be specific. "Torn ACL, Left Knee, Fell from An injury or illness is considered to be work- other potentially infectious materials, bandages, Band-Aids™, gauze pads, etc., Ladder" is an appropriate entry. related if an event or exposure in the work ● any case requiring an employee to be using Steri- Strips™, or butterfly bandages, environment caused or contributed to the resulting medically removed under the requirements of a ● using hot or cold therapy, Be sure to classify each injury or illness per the condition or significantly aggravated a pre-existing PEOSH or OSHA health standard, instructions on the forms. condition. |
● using any totally non-rigid means of support, ● a case of HIV infection, hepatitis, or Classifying Illnesses ear at 2000, 3000 or 4000 hertz, and the such as elastic bandages, wraps, non-rigid back tuberculosis, Be specific employee's total hearing is 25 dB or more above belts, etc., ● a needlestick injury or cut from a sharp audiometric zero (also averaged at 2000, 3000, ● using eye patches, object that is contaminated with another persons' Skin diseases or disorders and 4000 hertz) in the same ear(s). ● using simple irrigation or a cotton swab to blood or other potentially infectious materials (see Skin diseases or disorders are illnesses involving remove foreign bodies not embedded in or adhered 29 CFR 1904.8 for definitions), and the worker's skin that are caused by work All other illnesses to the eye, ● other illnesses, if the employee exposure to chemicals, plants, or other Examples: Heatstroke, sunstroke, heat ● using irrigation, tweezers or cotton swab or independently and voluntarily requests that his or substances. exhaustion, heat stress and other effects of other simple means to remove splinters or foreign her name not be entered on the log. environmental heat; freezing, frostbite and material from areas other than the eye, Examples: Contact dermatitis, eczema or rash other effects of exposure to lower ● using finger guards, You must not enter the employee's name on the Log caused by primary irritants and sensitizers or temperatures; decompression sickness; effects ● using massages, for these cases. Instead, you must enter "Privacy poisonous plants; oil acne; friction blisters, of ionizing radiation (isotopes, x-rays, Case" in the space normally used for the ● drinking fluids to relieve heat stress. chrome ulcers; inflammation of the skin. radium); effects of non-ionizing radiation employee's name (Column B). You must keep a (welding flash, ultra-violet rays, lasers); separate confidential list of the case numbers and Respiratory conditions anthrax; bloodborne pathogenic diseases, How do you decide if the case involved restricted employee names for the establishment's privacy Respiratory conditions are illnesses associated such as AIDS, HIV, hepatitis B or hepatitis C; work? concern cases so that you can update the cases and with breathing hazardous biological agents, brucellosis; malignant or benign tumors; Restricted work activity occurs when, as the result provide information to the government, if chemicals, dust, gases, vapors, or fumes at work. histoplasmosis; coccidioidomycosis. of a work-related injury or illness, an employer or requested. health care professional keeps or recommends keeping, an employee from doing the routine Example: Silicosis, asbestosis, pneumonitis, When must you post the Summary? If you have a reasonable basis to believe that functions of his or her job or from working the full pharyngitis, rhinitis or acute congestion; You must post the Summary only -- not the Log information describing the privacy concern case workday that the employee would have been farmer's lung, beryllium disease, tuberculosis, -- by February 1st of the year following the may be personally identifiable, even though the scheduled to work before the injury or illness occupational asthma, reactive airways year covered by this form and keep it posted employees name has been omitted, you may use occurred. dysfunctional syndrome (RADS), chronic until April 30th of that year. discretion in describing the injury or illness or both obstructive pulmonary disease (COPD), on the OK300 and OK301 forms. You must enter hypersensitivity pneumonitis, toxic inhalation How long must you keep the Log, How do you count the number of days of enough information to identify the cause of the injury, such as metal fume fever, chronic Summary, or the Individual Injure/Illness restricted work activity or number of days away incident and the general severity of the injury or obstructive bronchitis, and other Report on file? from work? illness, but you need not include the details of an pneumoconiosis. You must keep the Log and Summary for 5 Count the number of calendar days, including intimate or private nature. years following the year to which they pertain. weekends and holidays (even if the employee was Poisoning These records must be available for review at not scheduled to work), that the employee was on work restrictions or was away from work as a result What if the outcome of the case changes? Poisoning includes disorders evidenced by all times. Individual Injury/Illness Reports of the injury or illness. Do not count the day on If the outcome or extent of an injury or illness abnormal concentrations of toxic substances in must be maintained for 30 years after the which the injury or illness occurred. Begin counting changes after you have recorded the case, simply blood, other tissues, other bodily fluids, or the employee is no longer employed by the State the days away from the day after the incident delete, or draw a line through the original entry. breath that are caused by the ingestion or of Oklahoma with any Public Sector employer. occurs. Then write the new entry where it belongs. absorption of toxic substances into the body. Remember, you need to record the most serious Do you have to send in these forms at the If a single injury or illness involves both days away outcome for each case. Examples: Poisoning by lead, mercury, end of the year? from work and days of restricted work activity, cadmium, arsenic or other metals; poisoning by All Public Employers must provide records as enter the total number of days for each. Classifying injuries carbon monoxide, hydrogen sulfide, or other part of the Annual Public Sector Survey, by gases; poisoning by benzene, benzol, carbon, submitting the information online, at You may stop counting days of restricted work or An injury is any wound or damage to the body tetrachloride, or other organic solvents; www.ok.gov/odol/public-sector-survey/ or by days away from work once the total of either, or resulting from an event in the work environment. poisoning by insecticide sprays, such as submitting copies of the requested the combination of both, reaches 180 days. parathion or lead arsenate; poisoning by other information. Participation in the Annual Examples: Cut, puncture, laceration, abrasion, chemicals such as formaldehyde. Public Sector Survey is mandatory. Failure to Under what circumstances should you NOT fracture, bruise, contusion, chipped or broken respond will result in a PEOSH inspection. enter the employee's name on form OK300? tooth, amputation, insect bite, electrocution or Hearing loss You must consider the following injuries or illnesses thermal, chemical, electrical or radiation burn. Noise-induced hearing loss is defined for How can we help you? to be privacy concern cases: Sprain and strain injuries to muscles, joints and recordkeeping purposes as a change in hearing If you have questions about how to fill out the ● an injury or illness to an intimate body part or connective tissues are classified as injuries when threshold relative to the baseline audiogram of Log, call us at (405) 521-6140 or toll free at 1- to the reproductive system, they result from a slip, trip, fall or other similar an average of 10 (decibels) dB or more in either 888-269-5353. ● an injury or illness resulting from a sexual accidents. assault, ● a mental illness, |
How to Fill Out the OK300 Log of Work-Related Injuries and Illnesses The Log is used to classify work-related injuries and illnesses and to note the extent and severity of each case. When an incident occurs, use the Log to record specific details about what happened and how it happened. If your agency or entity has more than one establishment or site, you must keep separate records for each physical location that is expected to remain in operation for one year or longer. Can an establishment include more than one physical location? Yes, but only if the direct daily supervision of all staff is the responsibility of one common individual. {See 380:40-1-5(a)(6) of the Oklahoma Occupational Health & Safety Standards.} The Summary -- shows the work-related injury and illness totals for the year in each category. At the end of the year, count the number of incidents in each category and transfer the totals from the Log to the Summary. The highest ranking official or other official must review and certify the Summary. From February 1 stto April 30 theth following year, post the Summary in a visible location so that your employees are aware of the injuries and illnesses occurring in their workplace. You do not post the Log. You only post the Summary at the end of the year. |
Recording Criteria Changes in Extent of or Outcome of Injury or Illness (a) Basic Requirement. You must consider an injury or illness to meet the Cases are not recordable: If, during the five-year period in which the Log is retained, there is a change in general recording criteria, and therefore to be recordable, if it results in any of an extent and outcome of an injury or illness which affects entries in columns the following: death, Days wayA from work, estrictedR work or ransferT to (G) (H) (I) or (J), the first entry should be lined out and a new entry made. For ● Visits to a physician or other another job, medical treatment beyond first aid, or loss of consciousness. You example, if an injured employee at first required only medical treatment with licensed health care professional must also consider a case to meet the general recording criteria if it involves a (LHCP) solely for observation or no lost work days but later lost days away from work, the check in column (J) significant injury or illness diagnosed by a physician or other licensed health counseling. should be lined out, and a check entered in column (H) and the number of days care professional, even if it does not result in death, days away from work, ● Diagnostic procedures, such as x- away from work entered in column (K). restricted work or job transfer, medical treatment beyond first aid, or loss of rays and blood tests, including the consciousness. administration of prescription In another example, if an employee with an occupational illness with days away medications solely for diagnostic from work, returned to work, and then died of the illness, any entries in column (b) Implementation. How do I decide if a case meets one or more of the purposes (e.g., eye drops to dilate (H) should be lined out and the death entered in column (G). general recording criteria? pupils). ● First Aid only (see the complete The entire entry for an injury or illness should be lined out if later found to be list on pages 2-3) non-recordable. This would include for example: an injury which is later A work-related injury or illness must be recorded if it results in one or more of determined not to be work-related or which was initially thought to involve the following: medical treatment but later was determined to have involved only first aid. 1) Death, 2) Days away from work, 3) Restricted work or transfer to another job, Diagnosis of Significant Injury or Illness 4) Medical treatment beyond first aid, 5) Loss of consciousness, Any serious or significant work-related disorder that is diagnosed by a 6) A significant injury or illness diagnosed by a physician or other Physician or other icensed L ealth H are CroviderP and/or identified by a licensed health care professional. positive medical test. These include work-related cases involving cancer, chronic irreversible disease, a fractured or a cracked bone or a punctured Recordkeeping Criteria Decision Tree eardrum. Calculating the Incident Rate You can compute your entities incident rate (IR) by utilizing the following formula. Total number of injuries X 200,000 # of hours worked by all = Incident and illnesses employees rate ________________ X 200,000 ÷_______________ = _______ What can I compare my incident rates to? Each year the Oklahoma Department of Labor analyzes data from the Annual Public Sector Survey. For details on the State’s Incident Rate, visit the ODOL website listed below. For additional information, you may call (405) 521-6140 or 1-888-269-5353 or visit our web site at: www.labor.ok.gov. Figure 1 - Ask yourself each of these questions to determine if a case is recordable. |
OK300 -- Log of Work-Related Injuries & Illnesses ATTENTION: This form contains information relating to employee health and Year ______ must be used in a manner that protects the confidentiality of employees to the extent Oklahoma Department of Labor possible while the information is being used for occupational safety and health purposes. 405-521-6140; 888-269-5353; www.labor.ok.gov You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work- Establishment related injuries that are diagnosed by a physician or licensed health care professional (PHLCP). You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two (2) single lines Physical Location for a single case if you need to. You must complete an Injury & Illness Incident Report (form OK301) for each injury or illness recorded on this form. If you’re not sure whether a case is recordable, call the Oklahoma Department of Labor for help at 1-888-269-5353. City, State, ZIP Identify the person Describe the case Classify the case Enter number of days (A) (B) (C) (D) (E) (F) CHECK ONLY ONE box for each case based injured or ill worker (M) Choose one type of illness: Case Employee's Name Job Title (e.g., Date of injury or Where the event occurred (e.g. Describe injury or illness, parts of on the most serious outcome for that case: was: Respiratory condition All other illnesses No. Welder) onset of illness Loading dock north end) body affected, and object/substance Death Days Remained at work Away On job Skin disorder Poisoning Hearing loss that directly injured or made person ill away from transfer Injury (e.g. Second degree burns on right forearm from acetylene torch) from On job Other work or work transfer recordable restriction or cases restriction (D) (days) (days) (A) (B) (C) MM DD (E) (F) (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) Public reporting burden for this collection of information is estimated to average 15 minutes per response, Page Totals: Respiratory condition All other illnesses including time to review the instruction, search and gather the data needed, and complete and review the (G) (H) (I) (J) (K) (L) Skin disorder Poisoning Hearing loss collection of information. Ensure totals to the Summary page (Form 300A) are accurate before you post it. Injury RETAIN FOR YOUR RECORDS !RECORDS MUST BE MAINTAINED FOR A MINIMUM OF FIVE YEAR . S (1) (2) (3) (4) (5) (6) |
Worksheet to help you fill out form OK300A - Summary of Work-Related Injuries & Illnesses Year ______ Oklahoma Department of Labor 405-521-6140; 888-269-5353; www.labor.ok.gov Optional At the end of the year, you are required to enter the average number of employees and the total hours worked by your employees on form OK300A. If you don't have these figures, you can use the information on this page to estimate the numbers you will need to enter on form OK300A at the end of the year. How to figure the average number of employees who worked for your establishment: Step 1: Add the total number of employees your establishment paid in all pay periods The number of employees paid in all pay periods = __________ during the year. Include all employees; full-time, part-time, temporary, seasonal, salaried, and hourly. Divided by Step 2: Count the number of pay periods your establishment had during the year. Be The number of pay periods during the year = __________ sure to include any pay periods when you had no employees. Rounded to the next whole number = __________ Step 3: Divide the number of employees by the number of pay periods. Step 4: Round the answer to the next highest whole number. Write the rounded number in the blank marked Annual average number of employees. For example, a public entity figured its average employment this way: For pay period Number of employees Paid Number of employees paid = 830 1 10 2 0 Number of pay periods = 26 3 15 4 30 830 ÷26 = 31.92 5 40 … … 31.92 rounds to 32 24 20 25 15 32 is the annual average number of employees 26 830 How to figure the total hours worked by all employees: Include the hours worked by salaried, hourly, part-time, and seasonal workers, as well as hours worked by other workers subject to day-to-day supervision by your establishment (e.g., temporary help services workers). Do not include vacation, sick leave, holidays, or any other non-work time, even if employees were paid for it. If your establishment keeps records of only the hours paid or if you have employees who are not paid by the hour, estimate the hours that the employees actually worked. If this number is not available, you can use this optional worksheet to estimate the number. Optional Worksheet Find the number of full-time employees in your establishment for the year. * Multiply by the number of work hours for a full-time employee per year. This is the number of full-time hours worked. + Add the number of any overtime hours as well as the hours worked by other employees (part-time, temporary, seasonal). Round the answer to the next highest whole number. Write the rounded number in the blank marked Total hours worked by all employees last year. |
Year ______ OK300A -- Summary of Work-Related Injuries & Illnesses Mandatory Oklahoma Department of Labor 405-521-6140; 888-269-5353; www.labor.ok.gov Section 1: Establishment Information Establishment Facility ID Location Physical Address Mailing Address Physical City Mailing City, State ZIP Mailing State Mailing Zip Telephone Instructions: All establishments covered by Part 1904 must complete the questions below, even if no work-related injuries or illnesses occurred during the year. Remember to review the OK300 Log to verify that the entries are complete and accurate before completing this summary. Using the Log, count the individual entries you made for each category. Then write the total below, making sure you've added the entries from every page of the Log. If you had no cases, enter "0". Employees, former employees, and their representatives have the right to review the OK300 Log in its entirety. They also have limited access to the OK300 Log or its equivalent. See 29 CFR Part 1904.35, in OSHA's recordkeeping rule, for further details on the access provisions of these forms. If you have questions or need assistance, call the Oklahoma Department of Labor at 1-888-269-5353. 1. Annual average number of employees: 2. Total hours worked by all employees last year: 3. Check any conditions that might have affected your answers to questions 1 and 2 above during this reporting year: Strike or lockout Natural disaster or adverse weather conditions Other reason: Shutdown or layoff Shorter work schedules or fewer pay periods than usual Nothing unusual happened to affect our employment or hours figures. Seasonal work Longer work schedules or more pay periods than usual 4. Did you have ANY occupational injuries or illnesses during this reporting year Yes. Go to Section 2: form OK300A -- Summary of Work-Related Injuries and Illnesses … No. Go to Section 3: Contact Information and Certification… Section 2: OK300A -- Summary of Work-Related Injuries and Illnesses, YEAR: ______ Number of cases Total number Total number of cases with Total number of Total number of of deaths days away from work cases with job other recordable transfer or cases restriction For each case in Column G or H complete form OK301 – Injury & Illness Report -- Case Information (G) (H) (I) (J) Number of days Total number of Total number of days of Facility Incident Rate Calculator days away job transfer or restriction from work Injuries/Illness Multiplier Employees Hours Incident Rate * 200000 ÷ = (K) (L) Injury & Illness types Total number of… (M) The total Number of Cases recorded above in (1) Injuries (4) Poisonings G + H + I + J must equal total Injury & (2) Skin disorders (5) Hearing loss Illnesses Types recorded left in M (1 + 2 + 3 + 4 + 5 + 6). (3) Respiratory condition (6) All other illnesses Section 3: Contact Information and Certification (Knowingly falsifying this document may result in fines, legal actions, or both.) I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate and complete. Name and signature of Agency Executive/Official Telephone Ext. Fax Number Title E-Mail Today's Date (MM/DD/YYYY) Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of information. If you have any comments about these estimates or any other aspects of this data collection, contact: Oklahoma Department of Labor, 3017 N Stiles, Suite 100, Oklahoma City, OK 73105; 1-888-269-5353. Post this Summary page from February 1st to April 30th, ______ |
Year ______ OK301 – Individual Injury & Illness Report -- Case Information Mandatory Oklahoma Department of Labor 405-521-6140; 888-269-5353; www.labor.ok.gov Case Information Facility ID YOU MUST COMPLETE FORM OK301 FOR EACH RECORDABLE CASE. When submitting for the Public Sector Survey, only include the form OK301 page(s) for incidents resulting in Cases with Days Away from Work (column H) or Death (column G). Case number Employee's Job Title Date of Injury/Illness Number of days Number of days of job transfer from Log name away from work or restriction (column D) (column A) (column B) (column C) MM DD YYYY (column K) (column L) Tell us about the Employee Tell us about the Incident 1. Check the category which best describes the employee's regular type of job or work: 6. Time employee began work: am pm (optional) Construction Healthcare 7. Time of event: am pm Sales Delivery or driving OR Check if time cannot be determined Food service Farming Event occurred: before during after work shift Repair, installation or service of Cleaning, Maintenance of building, machines, equipment grounds 8. What was the employee doing just before the incident occurred? Describe the activity as well as Office, professional, business, or Material handling (e.g. stocking, the tools, equipment, or material the employee was using. Be Specific. Examples: "climbing a ladder management staff loading/unloading, moving, etc.) while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry." Product assembly, product Other: manufacture 2. Employee's race or ethnic background: (optional-check one or more) 9. What happened? Tell us how the injury or illness occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; Worker was sprayed with chlorine when gasket broke during replacement"; American Indian or Alaska Native "Worker developed soreness in wrist over time." Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White 10. What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or "sore." (These are symptoms, not injuries.) Examples: Not available "strained back"; "chemical burn, hand"; "carpal tunnel syndrome." 3. Employee's age: AND Date of Birth MM DD YYYY 4. Employee's date hired: 11. What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank. MM DD YYYY 5. Employee's sex: Male Female 12. Was the employee treated in an emergency room? Yes No Completed by Title 13. Was employee hospitalized overnight as an in-patient? Yes No Phone Date Completed 14. If the employee died, record date of death: MM DD YYYY RETAIN FOR YOUR RECORDS !RECORDS MUST BE MAINTAINED FOR A MINIMUM OF FIVE YEAR .S N P S E SS O |