Form 5020 – Fill Out and Use This PDF

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

CASE NUMBER

M

P

L

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

3a. Location Code

O

OWNERSHIP

Y

E

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

5. State unemployment insurance acct.no

R

6. TYPE OF EMPLOYER:

Private

State

County

City

School District

Other Gov't, Specify:

INDUSTRY

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

Yes

No

INJURY/ILLNESS (mm/dd/yy)

FORM (mm/dd/yy)

DAY WORKED?

Yes

No

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

I

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

R

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

WEEKLY WAGE

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

COUNTY

S

NATURE OF INJURY

PART OF BODY

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

EVENT

E