State of California Please complete in triplicate (type if possible) Mail two copies to: OSHA CASE NO.
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
FATALITY
Any person who makes or causes to be made any California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
knowingly false or fraudulent material statement or 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
material representation for the purpose of obtaining or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death
denying workers compensation benefits or payments is must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
guilty of a felony.
1. FIRM NAME Ia. Policy Number Please do not use
this column
E 2. MAILING ADDRESS: (Number, Street, City, Zip) 2a. Phone Number
M CASE NUMBER
P
L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip) 3a. Location Code
O OWNERSHIP
Y 5. State unemployment insurance acct.no
E 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
R
6. TYPE OF EMPLOYER: INDUSTRY
Private State County City School District Other Gov't, Specify:
7. DATE OF INJURY / ONSET OF ILLNESS 8. TIME INJURY/ILLNESS OCCURRED 9. TIME EMPLOYEE BEGAN WORK 10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
(mm/dd/yy) AM PM AM PM OCCUPATION
1 1. UNABLE TO WORK FOR AT LEAST ONE 12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK, CHECK THIS BOX:
FULL DAY AFTER DATE OF INJURY?
Yes No
15. PAID FULL DAYS WAGES FOR DATE OF 16. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM SEX
NJURY OR LAST
DAY WORKED? Yes No Yes No INJURY/ILLNESS (mm/dd/yy) FORM (mm/dd/yy)
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 AGE
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N 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) 20a. COUNTY 21. ON EMPLOYER'S PREMISES? DAILY HOURS
J
U Yes No
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Y 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop. 23. Other Workers injured or ill in this event?
Yes No DAYS PER WEEK
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
O
R
WEEKLY HOURS
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
I
L WEEKLY WAGE
L 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
N and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY
E
S COUNTY
S
27. Name and address of physician (number, street, city, zip) 27a. Phone Number NATURE OF INJURY
28. Hospitalized as an inpatient overnight? No Yes If yes then, name and address of hospital (number, street, city, zip) 28a. Phone Number
PART OF BODY
29. Employee treated in emergency room?
Yes No
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 SOURCE
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*.
30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm/dd/yy)
EVENT
33. HOME ADDRESS (Number, Street, City,Zip) 33a. PHONE NUMBER
E SECONDARY SOURCE
M
P 34. SEX 35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) 36. DATE OF HIRE (mm/dd/yy)
L
O Male Female
Y
E 37. EMPLOYEE USUALLY WORKS 37a. EMPLOYMENT STATUS 37b. UNDER WHAT CLASS CODE OF YOUR
E hours per day, days per week, total weekly hours regular, full-time part-time POLICY WHERE WAGES ASSIGNED
temporary seasonal EXTENT OF INJURY
38. GROSS WAGES/SALARY 39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
$ per Yes No
Completed By (type or print) Signature & Title Date (mm/dd/yy)
• 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. eor other insuranc
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.
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY