Free Employer's report of occupational injury or illness - California

State of California Please complete in triplicate (type if possible) Mail two copies to: EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS 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. 1. FIRM NAME 2. MAILING ADDRESS: (Number, Street, City, Zip) E M P L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip) O Y E 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc. R 6. TYPE OF EMPLOYER: Private
(mm/dd/yy)

OSHA CASE NO.

FATALITY

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.
Ia. Policy Number 2a. Phone Number CASE NUMBER 3a. Location Code OWNERSHIP 5. State unemployment insurance acct.no Please do not use this column

State

County

City

School District

Other Gov't, Specify: 10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)

INDUSTRY

7. DATE OF INJURY / ONSET OF ILLNESS 8. TIME INJURY/ILLNESS OCCURRED
AM PM

9. TIME EMPLOYEE BEGAN WORK
AM PM

OCCUPATION 14. IF STILL OFF WORK, CHECK THIS BOX:

1 1. UNABLE TO WORK FOR AT LEAST ONE 12. DATE LAST WORKED (mm/dd/yy) FULL DAY AFTER DATE OF INJURY?
Yes No

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

15. PAID FULL DAYS WAGES FOR DATE OF 16. SALARY BEING CONTINUED? NJURY OR LAST Yes No DAY WORKED? Yes No

17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM FORM (mm/dd/yy) INJURY/ILLNESS (mm/dd/yy)

SEX

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 I N 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) 20a. COUNTY J U R Y 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.

AGE

21. ON EMPLOYER'S PREMISES? Yes 23. Other Workers injured or ill in this event? Yes No No

DAILY HOURS

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 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 S

WEEKLY WAGE

COUNTY

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
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*.

30. EMPLOYEE NAME

31. SOCIAL SECURITY NUMBER

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

E M P 35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) L 34. SEX O Male Female Y 37a. EMPLOYMENT STATUS 37. EMPLOYEE USUALLY WORKS E regular, full-time E total weekly hours days per week, hours per day, temporary 38. GROSS WAGES/SALARY $ Completed By (type or print) per Signature & Title

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

33a. PHONE NUMBER
SECONDARY SOURCE

36. DATE OF HIRE (mm/dd/yy)
37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED EXTENT OF INJURY

part-time seasonal

39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)? Yes No 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 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.
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY