From 5020 - Employer'S Report Of Occupational Injury Or Illness
ADVERTISEMENT
1OSHA
State of California
Please complete in triplicate ( type, if possible). Mail two copies to:
Case No.
EMPLOYER’S REPORT
OF OCCUPATIONAL
_________
o Fatality
INJURY OR ILLNESS
Any person who makes or causes to be made any
NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness
Knowingly false or fraudulent material statement
which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. I f an employee
or material representation for the purpose of
subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge
obtaining or denying workers’ compensation
an amended report indicating death. In addition, every serious injury/illness, or death must be reported immediately by
benefits or payments is guilty of a felony.
Telephone or telegraph to the nearest office of the California Division Of Safely and Health.
1. FIRM NAME
1A. POLICY NUMBER
DO NOT USE
THIS COLUMN
2. MAILING ADDRESS
2A. PHONE NUMBER
Case No.
(Number and Street, City, Zip)
E
M
P
3. LOCATION, IF DIFFERENT FROM MAILING ADDRESS
3A. LOCATION CODE
Ownership
(Number And street, City ,Zip)
L
O
4. NATURE OF BUSINESS,
5. STATE UNEMPLOYMENT INSURANCE Acct. No.
Industry
e.g., painting contractor, wholesale grocer, sawmill, hotel, etc.
Y
E
R
6. TYPE OF EMPLOYER
Occupation
o
o
o
o
o
o
PRIVATE
STATE
CITY
COUNTY
SCHOOL DIST.
OTHER GOVERNMENT - SPECIFY ________________________
7. EMPLOYEE NAME
8. SOCIAL SECURITY NUMBER
9. DATE OF BIRTH (mm/dd/yy)
Sex
E
M
10. HOME ADDRESS (Number and Street, City, Zip)
10A. PHONE NUMBER
Age
P
L
O
11. SEX
12. OCCUPATION (
13. DATE OF HIRE (mm/dd/yy)
Daily Hours
Regular job title-NO initials, abbreviations or number)
Y
o MALE
o FEMALE
E
14. EMPLOYEE USUALLY WORKS
14A. EMPLOYMENT STATUS
14B. Under what class code of your
Day per week
(Check applicable status at time of injury)
E
hours
days
total
regular
policy were wages assigned?
______ per day ______ per week ______ weekly hours ______ full-time
______ part-time
______ temporary
______ seasonal
15. GROSS WAGES/SALARY
16. OTHER PAYMENTS NOT REPORTED AS WAGES SALARY (e.g., tips, meal, lodging, overtime, bonuses, etc.) ?
Weekly hours
o YES
o NO
per
$ _______________ per _______________
, $ __________________
___________________
17. DATE OF INJURY OR ONSET OF ILLNESS
18. TIME INJURY/ILLNESS OCCURRED
19. TIME EMPLOYEE BEGAN WORK
20. IF EMPLOYEE DIED, DATE OF DEATH
Weekly wage
(mm/dd/yy)
(mm/dd/yy)
__________ A.M. __________ P.M.
__________ A.M. __________ P.M.
21. UNABLE TO WORK FOR AT LEAST ONE FULL DAY
22. DATE LAST WORKED
23. DATE RETURNED TO WORK
24. IF STILL OFF WORK
County
(mm/dd/yy)
AFTER DATE OF INJURY?
CHECK THIS BOX
o
o
o
YES
NO
25. PAID FULL WAGES FOR DAY OF INJURY OR
26. SALARY BEING CONTINUED?
27. DATE OF EMPLOYER’S KNOWLEDGE
28. DATE EMPLOYEE WAS PROVIDED
Nature of Injury
LAST DAY WORKED?
NOTICE OF INJURY/ILLNESS
EMPLOYEE CLAIM FROM
o
o
o
o
YES
NO
YES
NO
(mm/dd/yy)
(mm/dd/yy)
29. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS,
Part of Body
if available, e.g., second degree burns on right arm, tendonitis of left elbow, lead poisoning
I
N
J
U
30. LOCATION WHERE EVENT OR EXPOSURE OCCURRED
30A. COUNTY
30B. ON EMPLOYER’S PREMISES?
Source
(Number, Street, City)
o
o
R
YES
NO
Y
31. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED,
32. OTHER WORKERS INJURED/ILL IN THIS EVENTS
Event
e.g., shipping department, machine shop
o
o
O
YES
NO
R
33. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED,
Sec. Source
e.g., acetylene, welding torch, farm tractor, scaffold.
34. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED,
Extent of injury
e.g., welding seams of metal forms, loading boxes onto truck.
I
L
L
35. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS,
e.g., worker stepped back to
N
USE SEPARATE SHEET NECESSARY
inspect work and slipped on scrap materiel. As he fell , he brushed against fresh weld, and burned right hand.
.
E
S
S
36. NAME AND ADDRESS OF PHYSICIAN
36A. PHONE NUMBER
(Number and street, City, Zip)
37. IF HOSPITALIZED AS AN INPATIENT, NAME AND ADDRESS OF HOSPITAL
37A. PHONE NUMBER
(Number and Street, City, Zip)
Completed by (type or print)
Signature
Title
Date
FROM 5020 (REV. 6)
FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY
1992
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 5020 - Employer's Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form
Business
Tennessee Department Of Labor And Workforce Development Employer's First Report Of Work Injury Or Illness
Legal
Related Categories
Parent category: Legal