Form 5020 - Employer'S Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form

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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

2. MAILING ADDRESS: (Number, Street, City, Zip)

2a. Phone Number

CASE NUMBER

3. LOCATION if different from Mailing Address (Number, Street, City and Zip)

3a. Location Code

OWNERSHIP

4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.

5. State unemployment insurance acct.no

6. TYPE OF EMPLOYER:

INDUSTRY

City

School District

Private

State

County

Other Gov't, Specify:

8. TIME INJURY/ILLNESS OCCURRED

10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)

7. DATE OF INJURY / ONSET OF ILLNESS

9. TIME EMPLOYEE BEGAN WORK

(mm/dd/yy)

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

15. PAID FULL DAYS WAGES FOR DATE OF

18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM

17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF

SEX

16. SALARY BEING CONTINUED?

NJURY OR LAST

FORM (mm/dd/yy)

INJURY/ILLNESS (mm/dd/yy)

Yes

DAY WORKED?

Yes

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

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)

DAILY HOURS

20a. COUNTY

21. ON EMPLOYER'S PREMISES?

Yes

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.

23. Other Workers injured or ill in this event?

DAYS PER WEEK

Yes

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold

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.

WEEKLY WAGE

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

and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY

COUNTY

27. Name and address of physician (number, street, city, zip)

27a. Phone Number

NATURE OF INJURY

28a. Phone Number

Yes

If yes then, name and address of hospital (number, street, city, zip)

28. Hospitalized as an inpatient overnight?

PART OF BODY

29. Employee treated in emergency room?

Yes

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

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

31. SOCIAL SECURITY NUMBER

EVENT

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

33a. PHONE NUMBER

SECONDARY SOURCE

35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

34. SEX

36. DATE OF HIRE (mm/dd/yy)

Male

Female

37b. UNDER WHAT CLASS CODE OF YOUR

37a. EMPLOYMENT STATUS

37. EMPLOYEE USUALLY WORKS

POLICY WHERE WAGES ASSIGNED

part-time

regular, full-time

hours per day,

days per week,

total weekly hours

temporary

seasonal

EXTENT OF INJURY

39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?

38. GROSS WAGES/SALARY

per

Yes

Date (mm/dd/yy)

Signature & Title

Completed By (type or print)

• 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