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1 • • <br /> 1 <br /> 1 ATTACHMENT B <br /> ACCIDENT REPORT FORM <br /> 1 This form is required by Public Law 91-596 and must be Case of He No. <br /> kept in the establishments for 5 years. Failure to <br /> 1 maintain can result in the issuance of citations and <br /> assessment of penalties. <br /> Location of Office: <br /> 1 1. Name <br /> 2. Mail address (No. and street, city or town, State, and zip code) <br /> 1 3. Location if different from mail address <br /> Injured or III Employee <br /> 1 4. Name (First, middle, and last) Social Security No. <br /> 5. Home address No. and street city or town State and zip code <br /> 1 6. A e 17. Sex Check one Male ❑ Female ❑ <br /> 8. Occupation (Enter regular job title, not the specific activity he was performing at time <br /> of injury.) <br /> 1 9. Department (Enter name of department of division in which the injured person is <br /> regularly employed, even though he may have been temporarily working in another <br /> 1 department at the time of injury.) <br /> The Accident or Exposure to Occupational Illness <br /> 1 If accident or exposure occurred on employer's premises, give address of plant or <br /> establishment in which it occurred. Do not indicate department or division within the plant or <br /> establishment. If accident occurred outside employer's premises at an identifiable address, <br /> 1 give that address. If it occurred on a public highway or at any other place which cannot be <br /> identified by number and street, please provide place references locating the place of injury as <br /> accurately as possible. <br /> 1 10. Place of accident or exposure (No. And street, city or town, State and zip code) <br /> 1 11. Was place of accident or exposure on employer's remises? Yes ❑ No ❑ <br /> 12. What was the employee doing when injured? (Be specific. If he was using tools or <br /> 1 equipment or handling material, name them and tell what he was doing with them.) <br /> 1 <br /> 1 <br /> 1 902 Industrial Way•Lodi,CA 95240-209.367.3701 •Fax 209.333.9303 02014 Neil O.Anderson&Associates.Inc. <br />