Form K-Wc 1101-A - Employer'S Report Of Accident - 2006 Page 2
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1
2OSHA Case Information
(not to be filed with the Division of Workers Compensation)
25. Case number from the Log __________________ (Transfer the case number from the Log after you record the case.)
26. Date of injury or illness _____________________
27. Time employee began work _________________ A.M. / P.M.
28. Time of event _____________________________ A.M. / P.M.
Check if time cannot be determined.
29. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools,
equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing
materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."
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30. What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet";
"Worker was spraying with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over
time."
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31. 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." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
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32. 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 blank.
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33. If the employee died, when did death occur? Date of death ______________________________________________
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