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Appendix A: CAL/OSHA Form 301 <br /> Information about the employee <br /> Full name: <br /> Address: <br /> Date of birth: <br /> Date hired: <br /> Male: ❑ Female: ❑ <br /> Information about the physician or other health care professional <br /> Name of physician or other health care <br /> professional <br /> If treatment was given away from the <br /> worksite where was itgiven? <br /> Facility: <br /> Address: <br /> Was employee treated in an emergency Yes: ❑ No: ❑ <br /> room? <br /> Was employee hospitalized overnight as <br /> aYes: F1 No: El in-patient? <br /> Information about the case <br /> Case number from the log (Transfer the case <br /> number from the Log after you record the <br /> case. <br /> Date of injury or illness: <br /> Time employee began work: AM: PM: <br /> Time of event: AM: PM: <br /> Check if time cannot be determined: <br /> What was the employee doing just before the incident occurred? <br /> Describe the activity, as well as the tools, equipment, or material the employee was using. Be <br /> specific. <br /> Examples:"climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily <br /> computer key-entry." <br /> AEI Health&Safety,Injury&Illness Prevention Plan Page 17 of 25 <br /> June 24, 2011 <br />